Provider Demographics
NPI:1962915777
Name:JORGENSEN, BENJAMIN L
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:L
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:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:FAISON
Mailing Address - State:NC
Mailing Address - Zip Code:28341-0187
Mailing Address - Country:US
Mailing Address - Phone:910-267-2042
Mailing Address - Fax:855-996-9090
Practice Address - Street 1:801 TILGHMAN DR STE A
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-4958
Practice Address - Country:US
Practice Address - Phone:910-892-6500
Practice Address - Fax:910-892-1766
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT79432255A2300X
390200000X
NC0010-14498363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program