Provider Demographics
NPI:1376296467
Name:JESSICA BLAYLOCK DBA FUSION BODYWORKS PDX
Entity Type:Organization
Organization Name:JESSICA BLAYLOCK DBA FUSION BODYWORKS PDX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-281-8989
Mailing Address - Street 1:909 N BEECH ST UNIT 209
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1260
Mailing Address - Country:US
Mailing Address - Phone:503-281-8989
Mailing Address - Fax:
Practice Address - Street 1:909 N BEECH ST UNIT 209
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1260
Practice Address - Country:US
Practice Address - Phone:503-281-8989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty