Healthcare Provider Details

I. General information

NPI: 1669842993
Provider Name (Legal Business Name): JERI LYNN MIZE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 E MAIN ST
ROGUE RIVER OR
97537-9674
US

IV. Provider business mailing address

1142 FIELDER CREEK RD
ROGUE RIVER OR
97537-4645
US

V. Phone/Fax

Practice location:
  • Phone: 541-582-3838
  • Fax:
Mailing address:
  • Phone: 707-474-7025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number20822
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: