Provider Demographics
NPI:1881796324
Name:JORGENSEN, JACK DENZIL (DMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:DENZIL
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7107 NE VANCOUVER MALL DR
Mailing Address - Street 2:STE D
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-8179
Mailing Address - Country:US
Mailing Address - Phone:360-892-6555
Mailing Address - Fax:360-892-4170
Practice Address - Street 1:7107 NE VANCOUVER MALL DR
Practice Address - Street 2:SUITE #D
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-8178
Practice Address - Country:US
Practice Address - Phone:360-892-6555
Practice Address - Fax:360-892-4170
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009473122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist