Provider Demographics
NPI:1619628237
Name:MORTENSEN, JACKLYN ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:ANNE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 BULL LEA RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1247
Mailing Address - Country:US
Mailing Address - Phone:859-640-9165
Mailing Address - Fax:
Practice Address - Street 1:1350 BULL LEA RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-1247
Practice Address - Country:US
Practice Address - Phone:859-246-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
KYPA2925363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical