=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447750898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER L NIEVES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2018
-----------------------------------------------------
Last Update Date | 02/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15110 BOONES FERRY RD
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-3468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-238-7662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 470 RAILROAD AVE
-----------------------------------------------------
City | MOUNT ANGEL
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97362-9543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-984-4314
-----------------------------------------------------
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 | 23282
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------