Provider Demographics
NPI:1508030966
Name:WALTERS, JILL COURTNEY (LMT)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:COURTNEY
Last Name:WALTERS
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 1:51669 COLUMBIA RIVER HWY
Mailing Address - Street 2:STE. 130
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-4508
Mailing Address - Country:US
Mailing Address - Phone:503-543-8605
Mailing Address - Fax:503-210-8166
Practice Address - Street 1:51669 COLUMBIA RIVER HWY
Practice Address - Street 2:STE. 130
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-4508
Practice Address - Country:US
Practice Address - Phone:503-543-8605
Practice Address - Fax:503-210-8166
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist