Individual
MS. JAYDE THEOBALD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
4642 SE MADISON ST, PORTLAND, OR 97215-2572
(503) 313-6626
Mailing address
4642 SE MADISON ST, PORTLAND, OR 97215-2572
(503) 313-6626
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
16457
OR
Other
Enumeration date
09/04/2009
Last updated
10/30/2014
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