Healthcare Provider Details

I. General information

NPI: 1750374484
Provider Name (Legal Business Name): LAYNE S JORGENSEN DO, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2282 NW TROOST ST STE 103
ROSEBURG OR
97470-6071
US

IV. Provider business mailing address

2282 NW TROOST ST STE 103
ROSEBURG OR
97470-6071
US

V. Phone/Fax

Practice location:
  • Phone: 541-672-0497
  • Fax: 541-957-2663
Mailing address:
  • Phone: 541-672-0497
  • Fax: 541-957-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO19045
License Number StateOR

VIII. Authorized Official

Name: LAYNE S JORGENSEN
Title or Position: PRESIDENT
Credential: DO
Phone: 541-672-0497