=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700403235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ABIGAIL JORGENSEN DNP, FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2020
-----------------------------------------------------
Last Update Date | 12/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 E MARYDALE AVE
-----------------------------------------------------
City | SOLDOTNA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99669-7648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-262-3119
-----------------------------------------------------
Fax | 907-262-9290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2949
-----------------------------------------------------
City | SOLDOTNA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99669-2949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-262-3119
-----------------------------------------------------
Fax | 907-262-9290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 163063
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2019095768
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------