Provider Demographics
NPI:1376737585
Name:JORGENSON, MELISSA ANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:JORGENSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 BLOEMENDAAL DR
Mailing Address - Street 2:
Mailing Address - City:IPSWICH
Mailing Address - State:SD
Mailing Address - Zip Code:57451-2019
Mailing Address - Country:US
Mailing Address - Phone:605-426-6622
Mailing Address - Fax:
Practice Address - Street 1:617 BLOEMENDAAL DR
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:SD
Practice Address - Zip Code:57451-2019
Practice Address - Country:US
Practice Address - Phone:605-426-6622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0232225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant