Healthcare Provider Details

I. General information

NPI: 1659275709
Provider Name (Legal Business Name): JACQUELINE RENEE WADHAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SW 5TH ST
GRANTS PASS OR
97526-2509
US

IV. Provider business mailing address

406 DAVIDSON RD
WILLIAMS OR
97544-9604
US

V. Phone/Fax

Practice location:
  • Phone: 458-488-6587
  • Fax:
Mailing address:
  • Phone: 458-488-6587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0289955556
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: