Provider Demographics
NPI:1114269149
Name:JORGENSEN, SELENA (MD)
Entity Type:Individual
Prefix:DR
First Name:SELENA
Middle Name:
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 W BROADWAY
Mailing Address - Street 2:UNIT 3
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-1958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:363 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3703
Practice Address - Country:US
Practice Address - Phone:508-679-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA265850208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics