Provider Demographics
NPI:1063009850
Name:JURGENSON, ALICIA M (BS)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:JURGENSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:M
Other - Last Name:MARTINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 KESSEL CT STE 105
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6227
Mailing Address - Country:US
Mailing Address - Phone:608-280-2700
Mailing Address - Fax:
Practice Address - Street 1:322 DEWITT ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-2114
Practice Address - Country:US
Practice Address - Phone:608-745-9720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator