Provider Demographics
NPI:1427569052
Name:IRVIN, JONATHAN (LAC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:IRVIN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 SE 41ST AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3259
Mailing Address - Country:US
Mailing Address - Phone:206-305-8709
Mailing Address - Fax:
Practice Address - Street 1:2121 W BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3519
Practice Address - Country:US
Practice Address - Phone:503-432-8348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC184368171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist