Provider Demographics
NPI:1467772178
Name:BIVENS, JENNIFER MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:BIVENS
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 1:5331 SW MACADAM AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6104
Mailing Address - Country:US
Mailing Address - Phone:503-445-7999
Mailing Address - Fax:503-445-7997
Practice Address - Street 1:5331 SW MACADAM AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6104
Practice Address - Country:US
Practice Address - Phone:503-445-7999
Practice Address - Fax:503-445-7997
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7252225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist