=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598839680
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY ROBIN JORGENSEN DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2006
-----------------------------------------------------
Last Update Date | 06/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 S SHERMAN AVE
-----------------------------------------------------
City | NORTH PLATTE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69101-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-534-1870
-----------------------------------------------------
Fax | 308-534-1871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 S SHERMAN AVE
-----------------------------------------------------
City | NORTH PLATTE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69101-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-534-1870
-----------------------------------------------------
Fax | 308-534-1871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 639
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------