Healthcare Provider Details

I. General information

NPI: 1700665122
Provider Name (Legal Business Name): SKYLAR KAY JORGENSON OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 N ROCK RD
WICHITA KS
67226-1341
US

IV. Provider business mailing address

611 S LORRAINE AVE
WICHITA KS
67211-3025
US

V. Phone/Fax

Practice location:
  • Phone: 316-440-3316
  • Fax:
Mailing address:
  • Phone: 316-312-1899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberT-06054
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: