Provider Demographics
NPI:1053413047
Name:JENSEN, HEATHER MELLEN (OD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MELLEN
Last Name:JENSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31070 SW WILLAMETTE WAY W
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9565
Mailing Address - Country:US
Mailing Address - Phone:503-860-2084
Mailing Address - Fax:
Practice Address - Street 1:5125 SKYLINE RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9427
Practice Address - Country:US
Practice Address - Phone:503-361-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3168ATI152W00000X
WAOD00004093152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist