Provider Demographics
NPI:1295750248
Name:JORGUSON, KIMBERLY ANNE (MED)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:JORGUSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:JORGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:16701 WALLER RD E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98446-1337
Mailing Address - Country:US
Mailing Address - Phone:253-370-2062
Mailing Address - Fax:
Practice Address - Street 1:950 BROADWAY STE 404
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4454
Practice Address - Country:US
Practice Address - Phone:206-774-8557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61525524101YM0800X
WACG61111490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA164303OtherDEPT OF LABOR & INDUSTRIE
WA8933044OtherCRIME VICTIMS
WA4472JOOtherREGENCE BLUE SHIELD