Individual
JESSE LUCKETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMT
Contact information
Practice address
52 NE FREMONT ST, PORTLAND, OR 97212-2027
(503) 381-6636
Mailing address
52 NE FREMONT ST, PORTLAND, OR 97212-2027
(503) 381-6636
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
7005
OR
Other
Enumeration date
05/12/2012
Last updated
05/12/2012
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