Healthcare Provider Details

I. General information

NPI: 1780834200
Provider Name (Legal Business Name): SARA JEAN KJELLGREN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 S MAIN RD
LEBANON OR
97355-2482
US

IV. Provider business mailing address

32977 SAND RIDGE RD
LEBANON OR
97355-9266
US

V. Phone/Fax

Practice location:
  • Phone: 541-258-1983
  • Fax:
Mailing address:
  • Phone: 541-258-1604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13615
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: