Provider Demographics
NPI:1386035277
Name:REYNOLDS-JACKSON, SARAH (LMT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:REYNOLDS-JACKSON
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 1:1341 NE DEMPSEY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3704
Mailing Address - Country:US
Mailing Address - Phone:541-815-6769
Mailing Address - Fax:
Practice Address - Street 1:39 NW LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3310
Practice Address - Country:US
Practice Address - Phone:541-330-0334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20779225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist