Provider Demographics
NPI:1609315225
Name:MORTENSEN, JOHN (BCABA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 INDUSTRIAL LOOP S
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-6217
Mailing Address - Country:US
Mailing Address - Phone:904-269-0773
Mailing Address - Fax:
Practice Address - Street 1:175 INDUSTRIAL LOOP S
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-6217
Practice Address - Country:US
Practice Address - Phone:904-269-0773
Practice Address - Fax:904-269-9667
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-03-0899103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst