Provider Demographics
NPI:1821496795
Name:JURGENSEN, JACOB
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
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 1:129 E HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-1609
Mailing Address - Country:US
Mailing Address - Phone:715-926-3919
Mailing Address - Fax:
Practice Address - Street 1:129 E HUDSON ST
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-1609
Practice Address - Country:US
Practice Address - Phone:715-926-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5059-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor