=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073308110
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRSTEN M YERGENSEN PPS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2025
-----------------------------------------------------
Last Update Date | 04/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 S GOLD ST
-----------------------------------------------------
City | YREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96097-3110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-331-9711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 OREM ST
-----------------------------------------------------
City | MOUNT SHASTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96067-2426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-599-8707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 220187635
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------