Provider Demographics
NPI:1083813265
Name:MORTENSON, JACKIE LYNN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LYNN
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 610TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:IA
Mailing Address - Zip Code:51012-7024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1658 610TH ST
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:IA
Practice Address - Zip Code:51012-7024
Practice Address - Country:US
Practice Address - Phone:712-368-4304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01730225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist