Healthcare Provider Details

I. General information

NPI: 1811010200
Provider Name (Legal Business Name): JESSICA LYNN HODGES LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 EDGEWATER ST NW SUITE 120
SALEM OR
97304-4711
US

IV. Provider business mailing address

5290 BAXTER CT SE
SALEM OR
97306-1538
US

V. Phone/Fax

Practice location:
  • Phone: 503-949-4053
  • Fax: 503-339-2966
Mailing address:
  • Phone: 503-949-4053
  • Fax: 503-339-2966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12640
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: