MEDICARE: DR. NATHANIEL PAUL JENSEN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1427	SC

General Provider Information

NPI Number	:	1255411211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHANIEL PAUL JENSEN O.D.

Provider Business Mailing Address
First Line	:	34 WOODCROSS DR APT 924
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-2364
Country	:	US
Telephone Number	:	920-740-6207
Fax Number	:

Provider Business Practice Location Address
First Line	:	280 HARBISON BLVD STE T
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-2247
Country	:	US
Telephone Number	:	803-732-9200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	07/08/2007

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