Healthcare Provider Details

I. General information

NPI: 1891042784
Provider Name (Legal Business Name): JENNIFER L WYANT LMT, CMMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 SW MORRISON ST
PORTLAND OR
97205-2218
US

IV. Provider business mailing address

21131 S JUBB RD
ESTACADA OR
97023-8629
US

V. Phone/Fax

Practice location:
  • Phone: 503-732-0011
  • Fax: 678-666-7128
Mailing address:
  • Phone: 503-732-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18843
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number18843
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: