Healthcare Provider Details

I. General information

NPI: 1376234815
Provider Name (Legal Business Name): JENNIFER MCFALL LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56880 VENTURE LN
SUNRIVER OR
97707-2158
US

IV. Provider business mailing address

54620 CARIBOU DR
BEND OR
97707-2676
US

V. Phone/Fax

Practice location:
  • Phone: 541-420-0644
  • Fax:
Mailing address:
  • Phone: 541-554-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number27468
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: