Provider Demographics
NPI:1316912231
Name:JORGENSEN, CLAIRESE DANIEL
Entity type:Individual
Prefix:MRS
First Name:CLAIRESE
Middle Name:DANIEL
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8615 158TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-8932
Mailing Address - Country:US
Mailing Address - Phone:253-445-8724
Mailing Address - Fax:
Practice Address - Street 1:26015 104TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7647
Practice Address - Country:US
Practice Address - Phone:253-850-6480
Practice Address - Fax:253-850-6498
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00043245183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician