Provider Demographics
NPI:1578826947
Name:JORGENSEN, MARK LAVON (MS, PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LAVON
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 E 9500 S
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:UT
Mailing Address - Zip Code:84328-8903
Mailing Address - Country:US
Mailing Address - Phone:435-764-0710
Mailing Address - Fax:
Practice Address - Street 1:345 E 9500 S
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:UT
Practice Address - Zip Code:84328-8903
Practice Address - Country:US
Practice Address - Phone:435-764-0710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT269867-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist