Provider Demographics
NPI:1639508831
Name:MORTLOCK, JULIA (ND, LAC)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:MORTLOCK
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7121 SW 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1907
Mailing Address - Country:US
Mailing Address - Phone:541-979-6467
Mailing Address - Fax:
Practice Address - Street 1:16904 SE 1ST ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-8511
Practice Address - Country:US
Practice Address - Phone:541-979-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2015-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60416884171100000X
ORAC164766171100000X
WANT60416820175F00000X
OR2012175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist