Healthcare Provider Details

I. General information

NPI: 1710291588
Provider Name (Legal Business Name): JENNIFER PAULA ZACHARY LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2010
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SW 2ND ST
CORVALLIS OR
97333-4715
US

IV. Provider business mailing address

107 SW 2ND ST
CORVALLIS OR
97333-4715
US

V. Phone/Fax

Practice location:
  • Phone: 541-363-3100
  • Fax: 866-572-0412
Mailing address:
  • Phone: 541-363-3100
  • Fax: 866-572-0412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number17019
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: