Provider Demographics
NPI:1275189532
Name:TIJERINO, JUSTIN ALESSANDRO
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALESSANDRO
Last Name:TIJERINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 RIVER RD N STE A
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4648
Mailing Address - Country:US
Mailing Address - Phone:541-497-9969
Mailing Address - Fax:503-304-2226
Practice Address - Street 1:4630 RIVER RD N STE A
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4648
Practice Address - Country:US
Practice Address - Phone:503-304-2225
Practice Address - Fax:503-304-2226
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25320225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist