Provider Demographics
NPI:1548896491
Name:JORGENSEN, JACOB WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:WILLIAM
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 BLACK POWDER CIR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3415
Mailing Address - Country:US
Mailing Address - Phone:916-804-1155
Mailing Address - Fax:
Practice Address - Street 1:154 BLACK POWDER CIR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3415
Practice Address - Country:US
Practice Address - Phone:916-804-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-22
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135292207ZC0006X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology