Healthcare Provider Details

I. General information

NPI: 1962583815
Provider Name (Legal Business Name): JORGEN JENSEN L.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MT DIABLO BLVD 202
WALNUT CREEK CA
94596-4852
US

IV. Provider business mailing address

95 ARGONAUT 280
ALISO VIEJO CA
92656-4133
US

V. Phone/Fax

Practice location:
  • Phone: 925-256-1133
  • Fax: 925-256-0999
Mailing address:
  • Phone: 949-598-9999
  • Fax: 949-598-9990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC5477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: