Healthcare Provider Details

I. General information

NPI: 1699987123
Provider Name (Legal Business Name): JENNY ROCK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 SW BEAVERTON HILLSDALE HWY SUITE 5
PORTLAND OR
97225-1400
US

IV. Provider business mailing address

6504 SW BOUNDARY ST
PORTLAND OR
97225-1450
US

V. Phone/Fax

Practice location:
  • Phone: 503-890-9365
  • Fax:
Mailing address:
  • Phone: 503-345-7660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA0009869
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19379
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: