Provider Demographics
NPI:1396991162
Name:JORGENSEN, JASON JOSEPH (DO)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:JOSEPH
Last Name:JORGENSEN
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 1:2637 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:214-970-6817
Mailing Address - Fax:844-803-4513
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:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN9717208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DQ434OtherBCBS
TX2988909-01Medicaid
TX2035487-04Medicaid
TXTXB140062Medicare PIN
TXTXB152529Medicare PIN