Healthcare Provider Details

I. General information

NPI: 1144763285
Provider Name (Legal Business Name): ACUPUNCTURE BY JENN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 N MAIN AVE SUITE 201
GRESHAM OR
97030-7200
US

IV. Provider business mailing address

109 N MAIN AVE SUITE 201
GRESHAM OR
97030-7200
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-1999
  • Fax:
Mailing address:
  • Phone: 503-665-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number179910
License Number StateOR

VIII. Authorized Official

Name: JENNIFER HUDSON
Title or Position: OWNER
Credential: LAC
Phone: 503-665-1999