Provider Demographics
NPI:1477831402
Name:JERGENSEN, EMILEE NICOLE (DC)
Entity type:Individual
Prefix:
First Name:EMILEE
Middle Name:NICOLE
Last Name:JERGENSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:EMILEE
Other - Middle Name:NICOLE
Other - Last Name:JANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2444 NE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-6020
Mailing Address - Country:US
Mailing Address - Phone:503-667-1010
Mailing Address - Fax:503-667-2246
Practice Address - Street 1:2444 NE DIVISION ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-6020
Practice Address - Country:US
Practice Address - Phone:503-667-1010
Practice Address - Fax:503-667-2246
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor