Provider Demographics
NPI:1164481107
Name:JORGENSEN, SHELIS R (ADVANCED NURSE PRACT)
Entity Type:Individual
Prefix:
First Name:SHELIS
Middle Name:R
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:ADVANCED NURSE PRACT
Other - Prefix:
Other - First Name:SHELIS
Other - Middle Name:R
Other - Last Name:HARRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:209 W EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6952
Mailing Address - Country:US
Mailing Address - Phone:907-861-1450
Mailing Address - Fax:907-861-1460
Practice Address - Street 1:209 W EVERGREEN AVE STE A
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6952
Practice Address - Country:US
Practice Address - Phone:907-861-1450
Practice Address - Fax:907-861-1460
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCM3761171M00000X
AKNURU798363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1022309Medicaid
AK1022309Medicaid
AK153171Medicare PIN