Provider Demographics
NPI:1003978164
Name:KEARNS, JENNIFER GAMACHE (DACM, LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GAMACHE
Last Name:KEARNS
Suffix:
Gender:F
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6214 SE 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-7029
Mailing Address - Country:US
Mailing Address - Phone:609-477-9192
Mailing Address - Fax:
Practice Address - Street 1:4004 SE WOODSTOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7662
Practice Address - Country:US
Practice Address - Phone:503-777-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00048100171100000X
PAAK000846171100000X
ORAC01275171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500616924Medicaid
NJ364590178OtherTAX ID