Healthcare Provider Details

I. General information

NPI: 1013230309
Provider Name (Legal Business Name): JEANE GUMP LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NE 92ND AVE
VANCOUVER WA
98664-2541
US

IV. Provider business mailing address

113 NE 92ND AVE
VANCOUVER WA
98664-2541
US

V. Phone/Fax

Practice location:
  • Phone: 503-318-6957
  • Fax:
Mailing address:
  • Phone: 503-318-6957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12783
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60378603
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: