Individual
JACOB NICKERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMT
Contact information
Practice address
4305 SE ELLIS ST, PORTLAND, OR 97206-5758
(360) 672-1811
Mailing address
4305 SE ELLIS ST, PORTLAND, OR 97206-5758
(360) 672-1811
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
24524
OR
Other
Enumeration date
01/29/2019
Last updated
01/29/2019
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