Provider Demographics
NPI:1679601264
Name:JORGENSEN, GARY Q (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:Q
Last Name:JORGENSEN
Suffix:
Gender:M
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 901535
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84090-1535
Mailing Address - Country:US
Mailing Address - Phone:801-598-4187
Mailing Address - Fax:801-523-0263
Practice Address - Street 1:501 CHIPETA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1222
Practice Address - Country:US
Practice Address - Phone:801-598-4187
Practice Address - Fax:801-523-0263
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT103687-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC0144Medicaid