Provider Demographics
NPI:1164608527
Name:MACISAAC, JESSICA ERIN (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ERIN
Last Name:MACISAAC
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 1:1370 EMMONS DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2900
Mailing Address - Country:US
Mailing Address - Phone:503-569-1094
Mailing Address - Fax:503-391-9121
Practice Address - Street 1:2794 12TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-3159
Practice Address - Country:US
Practice Address - Phone:503-566-8456
Practice Address - Fax:503-931-9121
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13380225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist