MEDICARE: TANDY JURGENSEN LPC, LMFT

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	101Y00000X	Counselor	6401015001	MI
2	106H00000X	Marriage & Family Therapist	4101007646	MI

General Provider Information

NPI Number	:	1134904972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANDY JURGENSEN LPC, LMFT

Provider Business Mailing Address
First Line	:	10535 VERNON AVE
Second Line	:
City	:	HUNTINGTON WOODS
State	:	MI
Zip	:	48070-1565
Country	:	US
Telephone Number	:	248-979-1219
Fax Number	:

Provider Business Practice Location Address
First Line	:	628 E PARENT AVE
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-3765
Country	:	US
Telephone Number	:	248-221-2734
Fax Number	:

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

Provider Enumeration Date	:	08/29/2023
Last Update Date	:	01/13/2026

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