Basic Information
| Provider Information | |||||||||
| NPI: | 1790072924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VASILNEK | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8309 N KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616152170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096939540 | ||||||||
| FaxNumber: | 3096939754 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 W MAIN ST | ||||||||
| Address2: | STE 21 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616061200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096722273 | ||||||||
| FaxNumber: | 3096722274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2011 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046.010457 | IL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.