Provider Demographics
NPI:1477698173
Name:JORGENSEN, LAYNE S (DO)
Entity Type:Individual
Prefix:
First Name:LAYNE
Middle Name:S
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 W HARVARD AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2743
Mailing Address - Country:US
Mailing Address - Phone:541-677-6553
Mailing Address - Fax:541-677-7023
Practice Address - Street 1:1813 W HARVARD AVE STE 140
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2743
Practice Address - Country:US
Practice Address - Phone:541-677-6553
Practice Address - Fax:541-677-7023
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO19045207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR068064Medicaid
OR113172Medicare ID - Type UnspecifiedMEDICARE
OR068064Medicaid