Healthcare Provider Details

I. General information

NPI: 1831259761
Provider Name (Legal Business Name): JORGENSEN OPTICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3538 JERSEY RIDGE RD
DAVENPORT IA
52807
US

IV. Provider business mailing address

3538 JERSEY RIDGE RD
DAVENPORT IA
52807
US

V. Phone/Fax

Practice location:
  • Phone: 563-386-8170
  • Fax: 563-386-2216
Mailing address:
  • Phone: 563-386-8170
  • Fax: 563-386-2216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number183
License Number StateIA

VIII. Authorized Official

Name: MR. JERRY ALLEN JORGENSEN
Title or Position: OPTICIAN HEARING AID DISPENSER
Credential:
Phone: 563-386-8170