Provider Demographics
NPI:1124212733
Name:JORGENSEN, MARIBETH FRANCES (PLMHP)
Entity Type:Individual
Prefix:MISS
First Name:MARIBETH
Middle Name:FRANCES
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 NORTH 169TH STREET
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116
Mailing Address - Country:US
Mailing Address - Phone:402-813-2235
Mailing Address - Fax:
Practice Address - Street 1:3223 NORTH 169TH STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116
Practice Address - Country:US
Practice Address - Phone:402-813-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8084101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025257100Medicaid