Provider Demographics
NPI:1447750898
Name:NIEVES, JENNIFER L
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:NIEVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT ANGEL
Mailing Address - State:OR
Mailing Address - Zip Code:97362-9543
Mailing Address - Country:US
Mailing Address - Phone:503-984-4314
Mailing Address - Fax:
Practice Address - Street 1:15110 BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3468
Practice Address - Country:US
Practice Address - Phone:971-238-7662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23282225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist