Provider Demographics
NPI:1073882874
Name:JORGENSEN, KATHY A
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-3700
Mailing Address - Country:US
Mailing Address - Phone:315-368-6803
Mailing Address - Fax:
Practice Address - Street 1:1115 MOHAWK ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-3700
Practice Address - Country:US
Practice Address - Phone:315-368-6803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY488580163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse