Provider Demographics
NPI:1073308110
Name:YERGENSEN, KIRSTEN M (PPS)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:M
Last Name:YERGENSEN
Suffix:
Gender:
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 OREM ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2426
Mailing Address - Country:US
Mailing Address - Phone:707-599-8707
Mailing Address - Fax:
Practice Address - Street 1:609 S GOLD ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3110
Practice Address - Country:US
Practice Address - Phone:530-331-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220187635103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool