=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073995429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA SUZANNE PEDERSEN LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2015
-----------------------------------------------------
Last Update Date | 09/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 812 NW 12TH ST
-----------------------------------------------------
City | PENDLETON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-310-8572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 812 NW 12TH ST
-----------------------------------------------------
City | PENDLETON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97801-1232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-310-8572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 20139
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 60540879
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------