Provider Demographics
NPI:1922503168
Name:JORGENSON, JACK J (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:J
Last Name:JORGENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 S HOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-2930
Mailing Address - Country:US
Mailing Address - Phone:414-647-3920
Mailing Address - Fax:414-647-3920
Practice Address - Street 1:8020 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-2930
Practice Address - Country:US
Practice Address - Phone:414-647-3920
Practice Address - Fax:414-647-3920
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71960207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1922503168Medicaid