Provider Demographics
NPI:1639944408
Name:JORGENSEN, MIKAELA SUE (MAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:SUE
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14133 S ENSIGN PEAK CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6415
Mailing Address - Country:US
Mailing Address - Phone:801-819-8705
Mailing Address - Fax:
Practice Address - Street 1:150 E BULLDOG BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2676
Practice Address - Country:US
Practice Address - Phone:801-422-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13416952-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer