Provider Demographics
NPI:1831462597
Name:MORTENSEN, KJERSTEN CELESTE
Entity Type:Individual
Prefix:
First Name:KJERSTEN
Middle Name:CELESTE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:862 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3320
Mailing Address - Country:US
Mailing Address - Phone:435-723-1799
Mailing Address - Fax:
Practice Address - Street 1:862 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3320
Practice Address - Country:US
Practice Address - Phone:435-723-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency