Individual
JACQUELINE MARIE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
5408 SE 111TH AVE, PORTLAND, OR 97266-4148
(503) 803-8352
Mailing address
5408 SE 111TH AVE, PORTLAND, OR 97266-4148
(503) 803-8352
Taxonomy
Speciality
Code
Description
License number
State
247200000X
Other Technician
Primary
3453
OR
Other
Enumeration date
04/05/2013
Last updated
04/05/2013
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