Healthcare Provider Details

I. General information

NPI: 1366953754
Provider Name (Legal Business Name): JASON W JORGENSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N MAIN ST
EPHRAIM UT
84627-1155
US

IV. Provider business mailing address

561 N 2400 W
PROVO UT
84601-7268
US

V. Phone/Fax

Practice location:
  • Phone: 435-283-4076
  • Fax:
Mailing address:
  • Phone: 435-469-1364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10528188-1206
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: