Provider Demographics
NPI:1376012542
Name:ZELLER, JANINE ELISE (LMT LIC #24264)
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:ELISE
Last Name:ZELLER
Suffix:
Gender:F
Credentials:LMT LIC #24264
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4493 SE ROETHE RD APT D
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-5711
Mailing Address - Country:US
Mailing Address - Phone:206-310-9814
Mailing Address - Fax:
Practice Address - Street 1:4493 SE ROETHE RD APT D
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-5711
Practice Address - Country:US
Practice Address - Phone:206-310-9814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-17
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24264225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist