Provider Demographics
NPI:1407930456
Name:MORTENSEN, JON DERIK (PAC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DERIK
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 PACIFIC AVE STE 300
Mailing Address - Street 2:ATTN HR
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4488
Mailing Address - Country:US
Mailing Address - Phone:253-722-1540
Mailing Address - Fax:
Practice Address - Street 1:10510 GRAVELLY LAKE DR.
Practice Address - Street 2:COMMUNITY HEALTH CARE - LAKEWOOD CLINIC
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499
Practice Address - Country:US
Practice Address - Phone:253-589-7030
Practice Address - Fax:253-589-7033
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005073363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8469256Medicaid
WA8469256Medicaid