Healthcare Provider Details

I. General information

NPI: 1699301119
Provider Name (Legal Business Name): ETHAN JEFFRIES LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4253 SE 182ND AVE
GRESHAM OR
97030-5083
US

IV. Provider business mailing address

892 E HISTORIC COLUMBIA RIVER HWY
TROUTDALE OR
97060-2166
US

V. Phone/Fax

Practice location:
  • Phone: 503-661-5090
  • Fax:
Mailing address:
  • Phone: 309-370-9379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number25719
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: