Provider Demographics
NPI:1356838817
Name:HAUSMAN, JACQUELINE ANN (LMT)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:ANN
Last Name:HAUSMAN
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 1:119 NE 3RD ST.
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128
Mailing Address - Country:US
Mailing Address - Phone:503-434-5124
Mailing Address - Fax:
Practice Address - Street 1:119 NE 3RD ST.
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128
Practice Address - Country:US
Practice Address - Phone:503-434-5124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16195225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist