Provider Demographics
NPI:1538701933
Name:MORT, JARED ANDREW (APRN, CNS)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:ANDREW
Last Name:MORT
Suffix:
Gender:M
Credentials:APRN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2792 RHETT DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6259
Mailing Address - Country:US
Mailing Address - Phone:210-488-8143
Mailing Address - Fax:
Practice Address - Street 1:2792 RHETT DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-6259
Practice Address - Country:US
Practice Address - Phone:210-488-8143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004509364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11004509OtherFLORIDA BOARD OF NURSING APRN LICENSE AS A CLINICAL NURSE SPECIALIST