Provider Demographics
NPI:1235110800
Name:JORGENSEN, MARIA C (CNS)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:C
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 EAGLES WALK
Mailing Address - Street 2:STE F
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6342
Mailing Address - Country:US
Mailing Address - Phone:770-389-1025
Mailing Address - Fax:770-389-3030
Practice Address - Street 1:155 EAGLES WALK
Practice Address - Street 2:STE F
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6342
Practice Address - Country:US
Practice Address - Phone:770-389-1025
Practice Address - Fax:770-389-3030
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN098399364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS22374Medicare UPIN
GAGRP6171Medicare ID - Type Unspecified