Basic Information
| Provider Information | |||||||||
| NPI: | 1407930456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORTENSEN | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | DERIK | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1019 PACIFIC AVE STE 300 | ||||||||
| Address2: | ATTN HR | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984024488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537221540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10510 GRAVELLY LAKE DR. | ||||||||
| Address2: | COMMUNITY HEALTH CARE - LAKEWOOD CLINIC | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535897030 | ||||||||
| FaxNumber: | 2535897033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 06/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10005073 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8469256 | 05 | WA | MEDICAID |