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General NPI Number Information
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NPI Number | 1609519198
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Entity Type | Individual
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Provider Name | DERRICK RAY JORGENSEN
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Gender | Male
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Dates
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Enumeration Date | 04/14/2022
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Last Update Date | 01/28/2026
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Provider Practice Location Address
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Address Line | 3200 CHANNING WAY STE 206
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7546
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Country | US
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Telephone | 208-529-2230
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Fax | 208-561-8061
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Provider Business Mailing Address
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Address Line | 3200 CHANNING WAY STE 206
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7546
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Country | US
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Telephone | 208-716-5614
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Fax |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA-2250
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License Number State | ID
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