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General NPI Number Information
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NPI Number | 1669704045
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Entity Type | Individual
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Provider Name | JEREMIAH JORGENSEN P.A.
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Gender | Male
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Dates
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Enumeration Date | 02/09/2010
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Last Update Date | 06/09/2019
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Provider Practice Location Address
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Address Line | 3584 W 9000 S SUITE 405
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City | WEST JORDAN
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State | UT
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Zip | 84088-5710
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Country | US
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Telephone | 801-568-3480
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Fax | 801-568-3482
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Provider Business Mailing Address
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Address Line | 6460 MEDICAL CENTER ST STE 350
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City | LAS VEGAS
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State | NV
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Zip | 89148-2423
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Country | US
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Telephone | 702-255-6647
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Fax | 702-933-1444
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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 | 4597
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA2046
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License Number State | NV
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 8152398-1206
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License Number State | UT
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