Provider Demographics
NPI:1831259761
Name:JORGENSEN OPTICIANS INC
Entity type:Organization
Organization Name:JORGENSEN OPTICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN HEARING AID DISPENSER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:563-386-8170
Mailing Address - Street 1:3538 JERSEY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807
Mailing Address - Country:US
Mailing Address - Phone:563-386-8170
Mailing Address - Fax:563-386-2216
Practice Address - Street 1:3538 JERSEY RIDGE RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-386-8170
Practice Address - Fax:563-386-2216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X, 156FX1800X
IA183332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
No332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0370280001Medicare NSC