Healthcare Provider Details

I. General information

NPI: 1053413047
Provider Name (Legal Business Name): HEATHER MELLEN JENSEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5125 SKYLINE RD S
SALEM OR
97306-9427
US

IV. Provider business mailing address

31070 SW WILLAMETTE WAY W
WILSONVILLE OR
97070-9565
US

V. Phone/Fax

Practice location:
  • Phone: 503-361-5400
  • Fax:
Mailing address:
  • Phone: 503-860-2084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3168ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00004093
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: