Provider Demographics
NPI:1619539160
Name:JORGENSEN, SKYLER WILLIAM
Entity Type:Individual
Prefix:
First Name:SKYLER
Middle Name:WILLIAM
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LA PALOMA DR
Mailing Address - Street 2:
Mailing Address - City:RAWLINS
Mailing Address - State:WY
Mailing Address - Zip Code:82301-5111
Mailing Address - Country:US
Mailing Address - Phone:308-627-4908
Mailing Address - Fax:
Practice Address - Street 1:1102 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5335
Practice Address - Country:US
Practice Address - Phone:307-370-9175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1878225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPT-1878OtherSTATE LICENSE