Basic Information
| Provider Information | |||||||||
| NPI: | 1053556258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORGENSEN | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4285 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082361600 | ||||||||
| FaxNumber: | 2082366695 | ||||||||
| Practice Location | |||||||||
| Address1: | 3417 MERLIN DR | ||||||||
| Address2: | STE 102 | ||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085520850 | ||||||||
| FaxNumber: | 2085295011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2008 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.