Provider Demographics
NPI:1013230309
Name:GUMP, JEANE (LMP)
Entity Type:Individual
Prefix:
First Name:JEANE
Middle Name:
Last Name:GUMP
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 NE 92ND AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2541
Mailing Address - Country:US
Mailing Address - Phone:503-318-6957
Mailing Address - Fax:
Practice Address - Street 1:113 NE 92ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2541
Practice Address - Country:US
Practice Address - Phone:503-318-6957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12783225700000X
WAMA 60378603225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist