Healthcare Provider Details

I. General information

NPI: 1376156216
Provider Name (Legal Business Name): PETER E JORGENSON ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2020
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 LILLY RD NE
OLYMPIA WA
98506-5133
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-493-4083
  • Fax: 360-486-6436
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP61438592
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: