Provider Demographics
NPI:1528574340
Name:MYLO, JENIFER MARI (LAC)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:MARI
Last Name:MYLO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 SE 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3318
Mailing Address - Country:US
Mailing Address - Phone:503-740-5738
Mailing Address - Fax:
Practice Address - Street 1:5117 SE POWELL BLVD STE 5B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-3000
Practice Address - Country:US
Practice Address - Phone:503-683-2738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC183247171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty