Healthcare Provider Details

I. General information

NPI: 1750372645
Provider Name (Legal Business Name): SCOTT A JENS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 UNIVERSITY AVE SUITE 102
MIDDLETON WI
53562-5414
US

IV. Provider business mailing address

7601 UNIVERSITY AVE SUITE 102
MIDDLETON WI
53562-5414
US

V. Phone/Fax

Practice location:
  • Phone: 608-831-3366
  • Fax: 608-831-8470
Mailing address:
  • Phone: 608-831-3366
  • Fax: 608-831-8470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2434
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: