Provider Demographics
NPI:1841274867
Name:JORGENSEN, CAROLYN S (PT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:S
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 160TH ST S
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8508
Mailing Address - Country:US
Mailing Address - Phone:253-531-4100
Mailing Address - Fax:253-531-3795
Practice Address - Street 1:201 160TH ST S
Practice Address - Street 2:SUITE 301
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8508
Practice Address - Country:US
Practice Address - Phone:253-531-4100
Practice Address - Fax:253-531-3795
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8334377Medicaid
WAJO2103OtherREGENCE BLUE SHIELD
WA59042OtherSTATE WORKERS COMP #
WAAB07138Medicare ID - Type UnspecifiedMEDICARE #