Healthcare Provider Details

I. General information

NPI: 1366352056
Provider Name (Legal Business Name): JACOB MORTENSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5721 SEAMAN RD
OREGON OH
43616-2631
US

IV. Provider business mailing address

5721 SEAMAN RD
OREGON OH
43616-2631
US

V. Phone/Fax

Practice location:
  • Phone: 419-693-0661
  • Fax:
Mailing address:
  • Phone: 419-693-0661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLSP.01225
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: