Healthcare Provider Details

I. General information

NPI: 1851272033
Provider Name (Legal Business Name): LACEY JORGENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 S LETITIA ST APT 303
PHILADELPHIA PA
19106-3010
US

IV. Provider business mailing address

11 S LETITIA ST APT 303
PHILADELPHIA PA
19106-3010
US

V. Phone/Fax

Practice location:
  • Phone: 848-210-6568
  • Fax:
Mailing address:
  • Phone: 848-210-6568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA067192
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: