Healthcare Provider Details

I. General information

NPI: 1124214192
Provider Name (Legal Business Name): ANNA MARIE JORGENSEN LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 S MAIN ST
SPRINGTOWN TX
76082-2608
US

IV. Provider business mailing address

PO BOX 963
SPRINGTOWN TX
76082-0963
US

V. Phone/Fax

Practice location:
  • Phone: 817-681-9563
  • Fax:
Mailing address:
  • Phone: 817-681-9563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number198367
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: