Provider Demographics
NPI:1447770664
Name:MORTENSEN, JORDAN L (DPT)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:L
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 ATWOOD AVE
Mailing Address - Street 2:#107
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704
Mailing Address - Country:US
Mailing Address - Phone:715-571-8482
Mailing Address - Fax:
Practice Address - Street 1:323 W MONROE STREET
Practice Address - Street 2:
Practice Address - City:WYOCENA
Practice Address - State:WI
Practice Address - Zip Code:53969
Practice Address - Country:US
Practice Address - Phone:608-429-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13697-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist