Provider Demographics
NPI:1205183415
Name:MORTENSON, GRETHE JUNE (CRNP)
Entity type:Individual
Prefix:
First Name:GRETHE
Middle Name:JUNE
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:GRETHE
Other - Middle Name:JUNE M
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:2074 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-3372
Mailing Address - Country:US
Mailing Address - Phone:541-841-8110
Mailing Address - Fax:541-885-5512
Practice Address - Street 1:2074 S 6TH ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601
Practice Address - Country:US
Practice Address - Phone:541-841-8110
Practice Address - Fax:541-885-5512
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8585363L00000X
PASP029043363L00000X
MN1916363LA2200X, 363LN0000X
OR10015210363LN0000X, 363L00000X
AZ281915363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500827451Medicaid
WI1205183415Medicaid