Provider Demographics
NPI:1265543730
Name:JORGENSEN, KEVIN JERARD (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JERARD
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4642
Mailing Address - Country:US
Mailing Address - Phone:323-728-6070
Mailing Address - Fax:323-728-2912
Practice Address - Street 1:1217 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4642
Practice Address - Country:US
Practice Address - Phone:323-728-6070
Practice Address - Fax:323-728-2912
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13902OtherPA-LICENSE
CAGR0084062, 61, 64Medicaid
CAMJ0501141OtherDEA
CAS38353Medicare UPIN
CAW14041A,B,CMedicare ID - Type UnspecifiedALL (MTB,PAS, ELA)
CAGR0084062, 61, 64Medicaid