Provider Demographics
NPI:1306803267
Name:JORGENSEN, MICHAEL GORDON (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GORDON
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 BUCKEYE AVENUE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-8063
Mailing Address - Country:US
Mailing Address - Phone:515-233-9087
Mailing Address - Fax:515-233-6409
Practice Address - Street 1:1110 BUCKEYE AVENUE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-8063
Practice Address - Country:US
Practice Address - Phone:515-233-9087
Practice Address - Fax:515-233-6409
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06757111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0451641Medicaid
IAI14239OtherIOWA MEDICARE, GROUP
IA0451658Medicaid
IA37766OtherWELLMARK PROVIDER #
IA37766OtherWELLMARK PROVIDER #
IAI14239OtherIOWA MEDICARE, GROUP
IA0451641Medicaid