Provider Demographics
NPI:1164863304
Name:DEFOREST, JULIANNE KLINGBERG (BA, LMT, CIMT)
Entity Type:Individual
Prefix:
First Name:JULIANNE
Middle Name:KLINGBERG
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:BA, LMT, CIMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:786 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97351-2310
Mailing Address - Country:US
Mailing Address - Phone:503-510-2256
Mailing Address - Fax:
Practice Address - Street 1:786 S MAIN ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OR
Practice Address - Zip Code:97351-2310
Practice Address - Country:US
Practice Address - Phone:503-510-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7627174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist