Basic Information
| Provider Information | |||||||||
| NPI: | 1972780807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORGENSON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910221 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753910221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205197700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5133 N CENTRAL AVE STE 206 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022640608 | ||||||||
| FaxNumber: | 6022340417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3806 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MA1720603 | 01 | AZ | DEA | OTHER |