Provider Demographics
NPI:1376333872
Name:MORTENSEN, JUSTIN L
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:L
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 3RD AVE BLDG 38200
Mailing Address - Street 2:PMB 216
Mailing Address - City:FORT EISENHOWER
Mailing Address - State:GA
Mailing Address - Zip Code:30905
Mailing Address - Country:US
Mailing Address - Phone:414-573-1502
Mailing Address - Fax:
Practice Address - Street 1:201 3RD AVE BLDG 38200
Practice Address - Street 2:PMB 216
Practice Address - City:FORT EISENHOWER
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:414-573-1502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program