Healthcare Provider Details

I. General information

NPI: 1407930456
Provider Name (Legal Business Name): JON DERIK MORTENSEN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10510 GRAVELLY LAKE DR. COMMUNITY HEALTH CARE - LAKEWOOD CLINIC
LAKEWOOD WA
98499
US

IV. Provider business mailing address

1019 PACIFIC AVE STE 300 ATTN HR
TACOMA WA
98402-4488
US

V. Phone/Fax

Practice location:
  • Phone: 253-589-7030
  • Fax: 253-589-7033
Mailing address:
  • Phone: 253-722-1540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10005073
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: