Provider Demographics
NPI:1700138948
Name:JORGENSEN, KELLY MICHELLE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHELLE
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 GILE DR
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-2660
Mailing Address - Country:US
Mailing Address - Phone:763-355-4949
Mailing Address - Fax:608-850-4992
Practice Address - Street 1:245 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:SAUK CITY
Practice Address - State:WI
Practice Address - Zip Code:53583-1013
Practice Address - Country:US
Practice Address - Phone:608-644-9265
Practice Address - Fax:608-643-2629
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14432183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist