Provider Demographics
NPI:1609816511
Name:MORTENSEN, JILL (DO)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 N HIGH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-2530
Mailing Address - Country:US
Mailing Address - Phone:856-327-0182
Mailing Address - Fax:856-327-7381
Practice Address - Street 1:1203 N HIGH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-2530
Practice Address - Country:US
Practice Address - Phone:856-327-0182
Practice Address - Fax:856-327-7381
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB46459207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3853900Medicaid
479838UZ8Medicare ID - Type Unspecified
NJ3853900Medicaid