Healthcare Provider Details

I. General information

NPI: 1417140724
Provider Name (Legal Business Name): CONNIE JORGENSEN MSRNCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 PATRICK HENRY PKWY STE 225
MCDONOUGH GA
30253-4214
US

IV. Provider business mailing address

2340 PATRICK HENRY PKWY STE 225
MCDONOUGH GA
30253-4214
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax: 770-389-3030
Mailing address:
  • Phone: 770-389-8100
  • Fax: 770-389-3030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number098399
License Number StateGA

VIII. Authorized Official

Name: MARIA CONNIE JORGENSEN
Title or Position: PRESIDENT
Credential: M.S., R.N., C.N.S.
Phone: 770-389-8100