Healthcare Provider Details

I. General information

NPI: 1942704069
Provider Name (Legal Business Name): JENNIFER HURTH LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8317 SE 13TH AVE
PORTLAND OR
97202-7101
US

IV. Provider business mailing address

8124 SE 9TH AVE
PORTLAND OR
97202-6507
US

V. Phone/Fax

Practice location:
  • Phone: 262-227-9836
  • Fax:
Mailing address:
  • Phone: 262-227-9836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number185920
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: