Provider Demographics
NPI:1508514852
Name:JORGENSON, AMBERLEE
Entity Type:Individual
Prefix:
First Name:AMBERLEE
Middle Name:
Last Name:JORGENSON
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 1:1201 NORTH AVE W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6601
Mailing Address - Country:US
Mailing Address - Phone:920-492-0726
Mailing Address - Fax:
Practice Address - Street 1:1315 WYOMING ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-1725
Practice Address - Country:US
Practice Address - Phone:406-532-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-55303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health