Provider Demographics
NPI:1598838161
Name:JURGENSEN, NICOLE RENE (LMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENE
Last Name:JURGENSEN
Suffix:
Gender:F
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 NE GREENWOOD AVE
Mailing Address - Street 2:#203
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4569
Mailing Address - Country:US
Mailing Address - Phone:541-383-4600
Mailing Address - Fax:541-317-9018
Practice Address - Street 1:644 NE GREENWOOD AVE
Practice Address - Street 2:#203
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4569
Practice Address - Country:US
Practice Address - Phone:541-383-4600
Practice Address - Fax:541-317-9018
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10384225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist