Provider Demographics
NPI:1073031233
Name:JORGENSON, MARY LOUISE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE
Last Name:JORGENSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4014 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1053
Practice Address - Country:US
Practice Address - Phone:402-559-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1107363A00000X
NE2370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant