Healthcare Provider Details

I. General information

NPI: 1447770664
Provider Name (Legal Business Name): JORDAN L MORTENSEN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 W MONROE STREET
WYOCENA WI
53969
US

IV. Provider business mailing address

1924 ATWOOD AVE #107
MADISON WI
53704
US

V. Phone/Fax

Practice location:
  • Phone: 608-429-2181
  • Fax:
Mailing address:
  • Phone: 715-571-8482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13697-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: