Provider Demographics
NPI:1225990195
Name:JORGENSEN, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 SAYLES RD
Mailing Address - Street 2:
Mailing Address - City:SARANAC
Mailing Address - State:MI
Mailing Address - Zip Code:48881-9472
Mailing Address - Country:US
Mailing Address - Phone:616-755-3802
Mailing Address - Fax:
Practice Address - Street 1:1000 E PARIS AVE SE STE 160
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8313
Practice Address - Country:US
Practice Address - Phone:231-668-4909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician