Provider Demographics
NPI:1407220916
Name:KISER, JACKIE RENEE (MA 60513345)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:RENEE
Last Name:KISER
Suffix:
Gender:F
Credentials:MA 60513345
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-1520
Mailing Address - Country:US
Mailing Address - Phone:509-310-9313
Mailing Address - Fax:
Practice Address - Street 1:820 OCEAN BEACH HWY
Practice Address - Street 2:STE 116
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4080
Practice Address - Country:US
Practice Address - Phone:360-200-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60513345225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist