Provider Demographics
NPI:1053413591
Name:JACK D JORGENSEN DMD PS
Entity type:Organization
Organization Name:JACK D JORGENSEN DMD PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DENZIL
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-892-6555
Mailing Address - Street 1:7107 NE VANCOUVER MALL DR
Mailing Address - Street 2:STE. #D
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-8178
Mailing Address - Country:US
Mailing Address - Phone:360-892-6555
Mailing Address - Fax:360-892-4170
Practice Address - Street 1:7107 NE VANCOUVER MALL DR
Practice Address - Street 2:STE. #D
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-8178
Practice Address - Country:US
Practice Address - Phone:360-892-6555
Practice Address - Fax:360-892-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009473261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental