MEDICARE: JESSICA NICOLE GULOVSEN LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	13966	OR

General Provider Information

NPI Number	:	1508134214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA NICOLE GULOVSEN LMT

Provider Business Mailing Address
First Line	:	690 54TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97478-6136
Country	:	US
Telephone Number	:	541-510-1101
Fax Number	:

Provider Business Practice Location Address
First Line	:	598 E 13TH AVE
Second Line	:	SUITE B
City	:	EUGENE
State	:	OR
Zip	:	97401-4783
Country	:	US
Telephone Number	:	541-762-1777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2011
Last Update Date	:	12/08/2011

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