Provider Demographics
NPI:1164537668
Name:JERGENSON, SHIRLEY C (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:C
Last Name:JERGENSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 BELLE RD
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-5220
Mailing Address - Country:US
Mailing Address - Phone:615-452-9356
Mailing Address - Fax:615-321-6360
Practice Address - Street 1:1310 24TH AVE S
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-2637
Practice Address - Country:US
Practice Address - Phone:615-327-4751
Practice Address - Fax:615-321-6360
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN361225100000X
WI750-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist