Provider Demographics
NPI:1861610479
Name:JORGENSEN, JUDITH M
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:M
Last Name:JORGENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 377
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-0377
Mailing Address - Country:US
Mailing Address - Phone:203-318-0742
Mailing Address - Fax:
Practice Address - Street 1:17 WALL ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3122
Practice Address - Country:US
Practice Address - Phone:203-318-0742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001500101YP2500X
IN20010513A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist