Provider Demographics
NPI:1154422822
Name:JENSEN, SHANE (OD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 592
Mailing Address - Street 2:
Mailing Address - City:PANGUITCH
Mailing Address - State:UT
Mailing Address - Zip Code:84759
Mailing Address - Country:US
Mailing Address - Phone:435-676-2761
Mailing Address - Fax:
Practice Address - Street 1:415 E. CENTER STREET
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759
Practice Address - Country:US
Practice Address - Phone:435-676-8646
Practice Address - Fax:435-676-8646
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5354482-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT53544829900001OtherBLUECROSS BLUESHIELD
UT043753766OtherTRICARE
UTD5075Medicaid
UT043753766OtherHUMANA
UT5354482-9934OtherPEHP
UT107028627101OtherIHC
UTRR27009OtherSPECTERA
UT270343OtherALTIUS
UT1595696OtherOPTICHOICE
UT813540OtherDMBA
UT043753766OtherTRICARE
UT107028627101OtherIHC