Basic Information
| Provider Information | |||||||||
| NPI: | 1619539160 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORGENSEN | ||||||||
| FirstName: | SKYLER | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 LA PALOMA DR | ||||||||
| Address2: | |||||||||
| City: | RAWLINS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 823015111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086274908 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1102 W SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | RAWLINS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 823015335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073709175 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2019 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1878 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT-1878 | 01 | WY | STATE LICENSE | OTHER |