Healthcare Provider Details

I. General information

NPI: 1316912231
Provider Name (Legal Business Name): MRS. CLAIRESE DANIEL JORGENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26015 104TH AVE SE
KENT WA
98030-7647
US

IV. Provider business mailing address

8615 158TH STREET CT E
PUYALLUP WA
98375-8932
US

V. Phone/Fax

Practice location:
  • Phone: 253-850-6480
  • Fax: 253-850-6498
Mailing address:
  • Phone: 253-445-8724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberVA00043245
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: