Provider Demographics
NPI:1679035489
Name:JURGENSEN, JOHN NICHOLAS
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:NICHOLAS
Last Name:JURGENSEN
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 1:91302 N COBURG INDUSTRIAL WAY STE 122
Mailing Address - Street 2:
Mailing Address - City:COBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97408-9331
Mailing Address - Country:US
Mailing Address - Phone:541-500-6949
Mailing Address - Fax:
Practice Address - Street 1:16811 SE MCGILLIVRAY BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3404
Practice Address - Country:US
Practice Address - Phone:360-735-8100
Practice Address - Fax:360-253-1781
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61240820363A00000X
ORPA200542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant