Provider Demographics
NPI:1548722010
Name:JORGENSEN, COLTON JAMES (COTA/L)
Entity type:Individual
Prefix:
First Name:COLTON
Middle Name:JAMES
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 SHERWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3562
Mailing Address - Country:US
Mailing Address - Phone:307-277-6219
Mailing Address - Fax:
Practice Address - Street 1:3100 OLYMPUS BLVD STE 500
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-5473
Practice Address - Country:US
Practice Address - Phone:866-221-5405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTA-1398224Z00000X
CA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty