=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790482057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORGENSEN FAMILY MEDICINE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2023
-----------------------------------------------------
Last Update Date | 06/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1813 W HARVARD AVE STE 140
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97471-2743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-677-6553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 PARADISE POINT LN
-----------------------------------------------------
City | ROSEBURG
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97471-8631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-430-7898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | DR. STEVEN JORGENSEN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 541-677-6553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------