Provider Demographics
NPI:1568986438
Name:JUERGENSEN, GARY (LMT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:JUERGENSEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MONT CLARE
Mailing Address - State:PA
Mailing Address - Zip Code:19453-5004
Mailing Address - Country:US
Mailing Address - Phone:267-240-9467
Mailing Address - Fax:
Practice Address - Street 1:715 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-2719
Practice Address - Country:US
Practice Address - Phone:484-879-4046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG005507225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist