Basic Information
| Provider Information | |||||||||
| NPI: | 1366105637 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORGENSEN | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | FNP | ||||||||
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| OtherLastName: | JORGENSEN | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | MAE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5050 LINDAHL RD | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558119707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183432672 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 927 TRETTEL LN | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557201345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2021 | ||||||||
| LastUpdateDate: | 10/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 8564 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.