Healthcare Provider Details

I. General information

NPI: 1093124828
Provider Name (Legal Business Name): JAMIE MANEHA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 SE MAIN ST
ROSEBURG OR
97470-3933
US

IV. Provider business mailing address

725 SE MAIN ST
ROSEBURG OR
97470-3982
US

V. Phone/Fax

Practice location:
  • Phone: 541-378-7789
  • Fax: 208-248-7717
Mailing address:
  • Phone: 541-378-7789
  • Fax: 208-248-7717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number17584
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: