Healthcare Provider Details

I. General information

NPI: 1609903467
Provider Name (Legal Business Name): JOLEEN LOUISE SMITH LMT, CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 N. RIVERSIDE AVE STE 115
MEDFORD OR
97501
US

IV. Provider business mailing address

1017 N. RIVERSIDE AVE STE 115
MEDFORD OR
97501
US

V. Phone/Fax

Practice location:
  • Phone: 541-660-0033
  • Fax: 541-479-3524
Mailing address:
  • Phone: 541-660-0033
  • Fax: 541-479-3524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12213
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: