Provider Demographics
NPI:1609089606
Name:MOURITSEN, JOLENE (EFDA)
Entity Type:Individual
Prefix:MS
First Name:JOLENE
Middle Name:
Last Name:MOURITSEN
Suffix:
Gender:F
Credentials:EFDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4892 LIBERTY RD. S. #177
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306
Mailing Address - Country:US
Mailing Address - Phone:503-378-9404
Mailing Address - Fax:
Practice Address - Street 1:5135 SKYLINE RD. S.
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306
Practice Address - Country:US
Practice Address - Phone:503-588-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR114153126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant