Provider Demographics
NPI:1225564016
Name:BLACKHURST, JENNA (LMT)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BLACKHURST
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 1:10914 SW 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-3611
Mailing Address - Country:US
Mailing Address - Phone:541-261-6482
Mailing Address - Fax:
Practice Address - Street 1:11415 SW SCHOLLS FERRY RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-7168
Practice Address - Country:US
Practice Address - Phone:541-261-6482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22171225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist