Provider Demographics
NPI:1457167330
Name:JORGENSON, JONAH THOMAS
Entity type:Individual
Prefix:
First Name:JONAH
Middle Name:THOMAS
Last Name:JORGENSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 S 41ST ST APT 303A
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7326
Mailing Address - Country:US
Mailing Address - Phone:904-558-4032
Mailing Address - Fax:
Practice Address - Street 1:2424 S 41ST ST APT 303A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7326
Practice Address - Country:US
Practice Address - Phone:904-558-4032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician