Provider Demographics
NPI:1902960347
Name:JENTERPRISES PS
Entity Type:Organization
Organization Name:JENTERPRISES PS
Other - Org Name:RENTON VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-255-2020
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-0353
Mailing Address - Country:US
Mailing Address - Phone:425-255-2020
Mailing Address - Fax:425-255-2028
Practice Address - Street 1:112 PELLY AVE N
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5713
Practice Address - Country:US
Practice Address - Phone:425-255-2020
Practice Address - Fax:425-255-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1722 TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2021467Medicaid
WAAB03693Medicare PIN
WAT70507Medicare UPIN
WA5793900001Medicare NSC