Healthcare Provider Details

I. General information

NPI: 1538709704
Provider Name (Legal Business Name): JORDAN CHARLES SMITH LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. JORDAN CHARLES GATES

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 MENROE ST.
EUGENE OR
97402
US

IV. Provider business mailing address

775 MENROE ST.
EUGENE OR
97402
US

V. Phone/Fax

Practice location:
  • Phone: 541-762-2009
  • Fax: 541-762-0499
Mailing address:
  • Phone: 541-762-2009
  • Fax: 541-762-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number24458
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: