Provider Demographics
NPI:1093950354
Name:MCDOUGAL, JACQULYN MAXINE (LMT)
Entity Type:Individual
Prefix:
First Name:JACQULYN
Middle Name:MAXINE
Last Name:MCDOUGAL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7149 SW SAGERT ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8261
Mailing Address - Country:US
Mailing Address - Phone:503-706-3833
Mailing Address - Fax:
Practice Address - Street 1:8755 SW CHRISTINE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070
Practice Address - Country:US
Practice Address - Phone:503-682-1110
Practice Address - Fax:503-682-1118
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1582172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist