MEDICARE: DR. KENT CHARLES 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	3951TG	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	270049	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1841360633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENT CHARLES JENSEN O.D.

Provider Business Mailing Address
First Line	:	11703 HUEBNER RD
Second Line	:	SUITE 109
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1201
Country	:	US
Telephone Number	:	210-764-7575
Fax Number	:	210-764-7576

Provider Business Practice Location Address
First Line	:	11703 HUEBNER RD
Second Line	:	SUITE 109
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1201
Country	:	US
Telephone Number	:	210-764-7575
Fax Number	:	210-764-7576

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	06/06/2013

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