Healthcare Provider Details

I. General information

NPI: 1043459217
Provider Name (Legal Business Name): MARI L JORGENSEN D.P.T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 CENTRAL AVE SUITE 105
LOS ALAMOS NM
87544-3244
US

IV. Provider business mailing address

1350 CENTRAL AVE SUITE 105
LOS ALAMOS NM
87544-3244
US

V. Phone/Fax

Practice location:
  • Phone: 505-662-3384
  • Fax:
Mailing address:
  • Phone: 505-662-3384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3568
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: