Provider Demographics
NPI:1043459217
Name:JORGENSEN, MARI L (DPT)
Entity Type:Individual
Prefix:MS
First Name:MARI
Middle Name:L
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 CENTRAL AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3244
Mailing Address - Country:US
Mailing Address - Phone:505-662-3384
Mailing Address - Fax:
Practice Address - Street 1:1350 CENTRAL AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3244
Practice Address - Country:US
Practice Address - Phone:505-662-3384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist