Provider Demographics
NPI:1255890968
Name:JERGENSEN, JASON A (DO)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:A
Last Name:JERGENSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-0001
Mailing Address - Country:US
Mailing Address - Phone:619-532-6400
Mailing Address - Fax:
Practice Address - Street 1:NAVY MEDICINE BRANCH CLINIC-MCRD 35000 GUADAL CANAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-0001
Practice Address - Country:US
Practice Address - Phone:619-524-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102206319208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program