Basic Information
| Provider Information | |||||||||
| NPI: | 1841274867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORGENSEN | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 160TH ST S | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | SPANAWAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983878508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535314100 | ||||||||
| FaxNumber: | 2535313795 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 160TH ST S | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | SPANAWAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983878508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535314100 | ||||||||
| FaxNumber: | 2535313795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00003420 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8334377 | 05 | WA | MEDICAID | JO2103 | 01 | WA | REGENCE BLUE SHIELD | OTHER | 59042 | 01 | WA | STATE WORKERS COMP # | OTHER |