Healthcare Provider Details

I. General information

NPI: 1508357237
Provider Name (Legal Business Name): JENNIFER DYANN ZURITA-RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6504 NE SISKIYOU ST
PORTLAND OR
97217
US

IV. Provider business mailing address

6504 NE SISKIYOU ST
PORTLAND OR
97213-4572
US

V. Phone/Fax

Practice location:
  • Phone: 503-327-3819
  • Fax:
Mailing address:
  • Phone: 503-327-3819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number24192
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: