Provider Demographics
NPI:1295214245
Name:MORTENSON, JACQUELINE NICOLE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 RESEARCH WAY
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3453
Mailing Address - Country:US
Mailing Address - Phone:631-331-6400
Mailing Address - Fax:631-331-6865
Practice Address - Street 1:14 RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3453
Practice Address - Country:US
Practice Address - Phone:631-331-6400
Practice Address - Fax:631-331-6865
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY029121235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program