=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245082148
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONIA JORGENSEN PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2024
-----------------------------------------------------
Last Update Date | 04/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 UT-99
-----------------------------------------------------
City | FILLMORE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-743-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 N STATE ST
-----------------------------------------------------
City | JOSEPH
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84739-1208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-654-8963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 12273901-2402
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------