Provider Demographics
NPI:1174763965
Name:JORGENSEN, PATTI (MCOUNSELING, SSW)
Entity type:Individual
Prefix:
First Name:PATTI
Middle Name:
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:MCOUNSELING, SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87-3184 LEA RD
Mailing Address - Street 2:
Mailing Address - City:CAPTAIN COOK
Mailing Address - State:HI
Mailing Address - Zip Code:96704-8724
Mailing Address - Country:US
Mailing Address - Phone:808-328-2480
Mailing Address - Fax:
Practice Address - Street 1:615 PIIKOI STREET
Practice Address - Street 2:# 203
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814
Practice Address - Country:US
Practice Address - Phone:808-589-1829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7240462-3503104100000X
2072101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker