Individual
JON DERIK MORTENSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
10510 GRAVELLY LAKE DR., COMMUNITY HEALTH CARE - LAKEWOOD CLINIC, LAKEWOOD, WA 98499
(253) 589-7030
(253) 589-7033
Mailing address
1019 PACIFIC AVE STE 300, ATTN HR, TACOMA, WA 98402-4488
(253) 722-1540
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA10005073
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8469256
—
WA
Enumeration date
10/25/2006
Last updated
06/14/2012
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