Provider Demographics
NPI:1902482300
Name:JERGENSON, MARISA JEAN (RN, BSN, CADC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:JEAN
Last Name:JERGENSON
Suffix:
Gender:F
Credentials:RN, BSN, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 AVENUE M W
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5789
Mailing Address - Country:US
Mailing Address - Phone:515-576-7261
Mailing Address - Fax:515-955-7628
Practice Address - Street 1:211 AVENUE M W
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5789
Practice Address - Country:US
Practice Address - Phone:515-576-7261
Practice Address - Fax:515-955-7628
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21037101YA0400X
IA131852163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)