Provider Demographics
NPI:1952661035
Name:MORTENSON BERGER, JENNIE MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:MARIE
Last Name:MORTENSON BERGER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 RAFT AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-5909
Mailing Address - Country:US
Mailing Address - Phone:631-218-7574
Mailing Address - Fax:
Practice Address - Street 1:495 RAFT AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-5909
Practice Address - Country:US
Practice Address - Phone:631-218-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294260164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse