Individual
JACKIE DIANE WEAVER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
103 14TH ST # 2, ASTORIA, OR 97103-3973
(503) 791-9244
Mailing address
PO BOX 854, ASTORIA, OR 97103-0854
(503) 791-9244
Taxonomy
Speciality
Code
Description
License number
State
174H00000X
Health Educator
Primary
15713
OR
Other
Enumeration date
03/10/2011
Last updated
03/10/2011
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