Healthcare Provider Details

I. General information

NPI: 1073995429
Provider Name (Legal Business Name): JESSICA SUZANNE PEDERSEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 09/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 NW 12TH ST
PENDLETON OR
97801
US

IV. Provider business mailing address

812 NW 12TH ST
PENDLETON OR
97801-1232
US

V. Phone/Fax

Practice location:
  • Phone: 541-310-8572
  • Fax:
Mailing address:
  • Phone: 541-310-8572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number20139
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number60540879
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: