Healthcare Provider Details

I. General information

NPI: 1396378907
Provider Name (Legal Business Name): JENNIFER ANNE HEIDEMAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 7TH AVE
EUGENE OR
97401-2510
US

IV. Provider business mailing address

2982 BAILEY LN
EUGENE OR
97401-6925
US

V. Phone/Fax

Practice location:
  • Phone: 541-343-3477
  • Fax:
Mailing address:
  • Phone: 541-603-6123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number24576
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: