Provider Demographics
NPI:1033848379
Name:MORTENSEN, JENNIFER DESIREE (EDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DESIREE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LAPHAM, SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:61 RIVERS RD
Mailing Address - Street 2:
Mailing Address - City:SMITH
Mailing Address - State:NV
Mailing Address - Zip Code:89430-9702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 RIVERS RD
Practice Address - Street 2:
Practice Address - City:SMITH
Practice Address - State:NV
Practice Address - Zip Code:89430-9702
Practice Address - Country:US
Practice Address - Phone:775-636-1251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV35064103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool