Individual
JACK M WELLS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMT
Contact information
Practice address
4630 RIVER RD N, KEIZER, OR 97303-4648
(503) 999-8062
Mailing address
4792 LANCASTER DR NE APT 102, SALEM, OR 97305-1747
(503) 999-8062
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
11767
OR
Other
Enumeration date
05/04/2007
Last updated
07/08/2007
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