Healthcare Provider Details

I. General information

NPI: 1013355932
Provider Name (Legal Business Name): JASON JORGENSEN, DO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W MAIN ST
LEWISVILLE TX
75057-3641
US

IV. Provider business mailing address

2637 N WASHINGTON BLVD # 164
NORTH OGDEN UT
84414-2240
US

V. Phone/Fax

Practice location:
  • Phone: 214-970-6817
  • Fax: 682-593-0695
Mailing address:
  • Phone: 801-388-7745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberN9717
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN VAWTER
Title or Position: ADMINISTRATOR
Credential:
Phone: 801-388-7745