Provider Demographics
NPI:1689385577
Name:JORGENSON, JACQUELINE ANN
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:JORGENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:WNUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 BERGSLIEN ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:WI
Mailing Address - Zip Code:54002-2600
Mailing Address - Country:US
Mailing Address - Phone:715-684-1553
Mailing Address - Fax:715-684-1119
Practice Address - Street 1:1100 BERGSLIEN ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:WI
Practice Address - Zip Code:54002-2600
Practice Address - Country:US
Practice Address - Phone:715-684-1553
Practice Address - Fax:715-684-1119
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI228561163W00000X
WI13391363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse