Provider Demographics
NPI:1164627261
Name:COSSETTE, JERYL M (LMT)
Entity Type:Individual
Prefix:
First Name:JERYL
Middle Name:M
Last Name:COSSETTE
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 1:76372 ROCK RD
Mailing Address - Street 2:
Mailing Address - City:OAKRIDGE
Mailing Address - State:OR
Mailing Address - Zip Code:97463-9541
Mailing Address - Country:US
Mailing Address - Phone:541-782-4416
Mailing Address - Fax:
Practice Address - Street 1:76370 ROCK RD
Practice Address - Street 2:
Practice Address - City:OAKRIDGE
Practice Address - State:OR
Practice Address - Zip Code:97463-9541
Practice Address - Country:US
Practice Address - Phone:541-782-4416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6936111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation