Provider Demographics
NPI:1013355932
Name:JASON JORGENSEN, DO, PLLC
Entity Type:Organization
Organization Name:JASON JORGENSEN, DO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VAWTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-388-7745
Mailing Address - Street 1:2637 N WASHINGTON BLVD # 164
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2240
Mailing Address - Country:US
Mailing Address - Phone:801-388-7745
Mailing Address - Fax:
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3641
Practice Address - Country:US
Practice Address - Phone:214-970-6817
Practice Address - Fax:682-593-0695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9717208100000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005YWOtherBCBS