MEDICARE: JACOB NICKERSON LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	24524	OR

General Provider Information

NPI Number	:	1205390671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB NICKERSON LMT

Provider Business Mailing Address
First Line	:	4305 SE ELLIS ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-5758
Country	:	US
Telephone Number	:	360-672-1811
Fax Number	:

Provider Business Practice Location Address
First Line	:	4305 SE ELLIS ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-5758
Country	:	US
Telephone Number	:	360-672-1811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2019
Last Update Date	:	01/29/2019

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