Provider Demographics
NPI:1174651061
Name:JURGENSEN, DAVID THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:THOMAS
Last Name:JURGENSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-1354
Mailing Address - Country:US
Mailing Address - Phone:608-847-6194
Mailing Address - Fax:608-847-4374
Practice Address - Street 1:114 W STATE ST
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1354
Practice Address - Country:US
Practice Address - Phone:608-847-6194
Practice Address - Fax:608-847-4374
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2500-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38844600Medicaid
WI75769Medicare ID - Type Unspecified
WI38844600Medicaid