Provider Demographics
NPI:1336130889
Name:JORGENSEN, JESSE A (PAC)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:A
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1566 E 1700 S
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84105
Mailing Address - Country:US
Mailing Address - Phone:801-773-8644
Mailing Address - Fax:775-246-4186
Practice Address - Street 1:1580 W ANTELOPE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1160
Practice Address - Country:US
Practice Address - Phone:801-927-1632
Practice Address - Fax:801-927-1591
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA907363A00000X
CAPA17883363A00000X
UT6124415-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505904Medicaid
NVCC7683OtherBCBS
CA0PA178831Medicare ID - Type Unspecified
NV100679Medicare ID - Type Unspecified
NV100505904Medicaid