Provider Demographics
NPI:1407802564
Name:MORTENSEN, JOHN A
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1107
Mailing Address - Country:US
Mailing Address - Phone:414-774-4200
Mailing Address - Fax:414-774-6828
Practice Address - Street 1:2255 S 108TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1107
Practice Address - Country:US
Practice Address - Phone:414-774-4200
Practice Address - Fax:414-774-6828
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI365-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist