Healthcare Provider Details

I. General information

NPI: 1649947334
Provider Name (Legal Business Name): AUSTIN DALE JENSEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16006 ASH WAY STE 101
LYNNWOOD WA
98087-6352
US

IV. Provider business mailing address

1795 NE 205TH ST APT 510
SHORELINE WA
98155-1017
US

V. Phone/Fax

Practice location:
  • Phone: 425-787-5200
  • Fax:
Mailing address:
  • Phone: 605-203-1129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOD-61171154
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: