Healthcare Provider Details

I. General information

NPI: 1285334060
Provider Name (Legal Business Name): JENNY KAY MORTENSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25147 TARA LYNN DR
NORTH OLMSTED OH
44070-1292
US

IV. Provider business mailing address

5269 DEVON DR
NORTH OLMSTED OH
44070-3038
US

V. Phone/Fax

Practice location:
  • Phone: 440-364-2975
  • Fax:
Mailing address:
  • Phone: 440-281-1485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberSW801321
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: