Healthcare Provider Details

I. General information

NPI: 1033848379
Provider Name (Legal Business Name): JENNIFER DESIREE MORTENSEN EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER LAPHAM, SHAFFER MA

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 RIVERS RD
SMITH NV
89430-9702
US

IV. Provider business mailing address

61 RIVERS RD
SMITH NV
89430-9702
US

V. Phone/Fax

Practice location:
  • Phone: 775-636-1251
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number35064
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: