Provider Demographics
NPI:1407260235
Name:REEVES, JENNY DIANE (LMT)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:DIANE
Last Name:REEVES
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 1:1840 SE 106TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2936
Mailing Address - Country:US
Mailing Address - Phone:971-322-8208
Mailing Address - Fax:
Practice Address - Street 1:1840 SE 106TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2936
Practice Address - Country:US
Practice Address - Phone:971-322-8209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11298174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist