Provider Demographics
NPI:1497293807
Name:JORGENSEN, ELIZABETH
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1081
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:956 WEST RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05254
Practice Address - Country:US
Practice Address - Phone:802-345-7216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer