Healthcare Provider Details

I. General information

NPI: 1962915777
Provider Name (Legal Business Name): BENJAMIN L JORGENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 TILGHMAN DR STE A
DUNN NC
28334-4958
US

IV. Provider business mailing address

PO BOX 187
FAISON NC
28341-0187
US

V. Phone/Fax

Practice location:
  • Phone: 910-892-6500
  • Fax: 910-892-1766
Mailing address:
  • Phone: 910-267-2042
  • Fax: 855-996-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT7943
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14498
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: