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General NPI Number Information
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NPI Number | 1053556258
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Entity Type | Individual
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Provider Name | MELINDA L JORGENSEN PHD
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Gender | Female
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Dates
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Enumeration Date | 12/03/2008
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Last Update Date | 12/15/2010
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Provider Practice Location Address
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Address Line | 3417 MERLIN DR STE 102
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7430
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Country | US
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Telephone | 208-552-0850
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Fax | 208-529-5011
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Provider Business Mailing Address
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Address Line | PO BOX 4285
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City | POCATELLO
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State | ID
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Zip | 83205-4285
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Country | US
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Telephone | 208-236-1600
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Fax | 208-236-6695
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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