Provider Demographics
NPI:1316944069
Name:JORGENSEN, JACKIE LYNN (APRN)
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LYNN
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:GOODLAND
Mailing Address - State:KS
Mailing Address - Zip Code:67735-1518
Mailing Address - Country:US
Mailing Address - Phone:785-890-6075
Mailing Address - Fax:785-890-6077
Practice Address - Street 1:106 WILLOW RD
Practice Address - Street 2:
Practice Address - City:GOODLAND
Practice Address - State:KS
Practice Address - Zip Code:67735-1518
Practice Address - Country:US
Practice Address - Phone:785-890-6075
Practice Address - Fax:785-890-6077
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0444331363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100419490CMedicaid
KS1316944069OtherBCBS
KSS54733Medicare UPIN
KS100419490CMedicaid