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General NPI Number Information
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NPI Number | 1194190298
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Entity Type | Individual
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Provider Name | JESSICA NIFOROS LMT
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Gender | Female
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Dates
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Enumeration Date | 12/01/2015
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Last Update Date | 12/08/2021
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Provider Practice Location Address
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Address Line | 629 SE 84TH AVE
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City | PORTLAND
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State | OR
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Zip | 97216-1105
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Country | US
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Telephone | 617-501-1365
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Fax |
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Provider Business Mailing Address
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Address Line | 7931 SE STARK ST SUITE200
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City | PORTLAND
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State | OR
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Zip | 97215
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Country | US
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Telephone | 617-501-1365
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 21848
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License Number State | OR
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