Provider Demographics
NPI:1669704045
Name:JORGENSEN, JEREMIAH (PA)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:PA
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Other - Credentials:
Mailing Address - Street 1:6460 MEDICAL CENTER ST STE 350
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-2423
Mailing Address - Country:US
Mailing Address - Phone:702-255-6647
Mailing Address - Fax:702-933-1444
Practice Address - Street 1:3584 W 9000 S
Practice Address - Street 2:SUITE 405
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5710
Practice Address - Country:US
Practice Address - Phone:801-568-3480
Practice Address - Fax:801-568-3482
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2019-06-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ4597363A00000X
NVPA2046363A00000X
UT8152398-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant