Provider Demographics
NPI:1144763285
Name:ACUPUNCTURE BY JENN
Entity Type:Organization
Organization Name:ACUPUNCTURE BY JENN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:503-665-1999
Mailing Address - Street 1:109 N MAIN AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7200
Mailing Address - Country:US
Mailing Address - Phone:503-665-1999
Mailing Address - Fax:
Practice Address - Street 1:109 N MAIN AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7200
Practice Address - Country:US
Practice Address - Phone:503-665-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR179910305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service