Provider Demographics
NPI:1053556258
Name:JORGENSEN, MELINDA L (PHD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:L
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:PHD
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 4285
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4285
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:3417 MERLIN DR
Practice Address - Street 2:STE 102
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7430
Practice Address - Country:US
Practice Address - Phone:208-552-0850
Practice Address - Fax:208-529-5011
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist