MEDICARE: JACLYN MICHELE MORTENSEN APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	124837	AR

General Provider Information

NPI Number	:	1679432926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACLYN MICHELE MORTENSEN APRN

Provider Business Mailing Address
First Line	:	3901 PARKWAY CIR
Second Line	:
City	:	SPRINGDALE
State	:	AR
Zip	:	72762-6362
Country	:	US
Telephone Number	:	479-587-1700
Fax Number	:	479-587-1366

Provider Business Practice Location Address
First Line	:	3901 PARKWAY CIR
Second Line	:
City	:	SPRINGDALE
State	:	AR
Zip	:	72762-6362
Country	:	US
Telephone Number	:	479-587-1700
Fax Number	:	479-587-1366

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2026
Last Update Date	:	01/21/2026

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