Provider Demographics
NPI:1558365965
Name:ST. JOHN, MARLA M (DC)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:M
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 12TH ST
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-9542
Mailing Address - Country:US
Mailing Address - Phone:541-386-1638
Mailing Address - Fax:541-308-0614
Practice Address - Street 1:1942 12TH ST
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-9542
Practice Address - Country:US
Practice Address - Phone:541-386-1638
Practice Address - Fax:541-308-0614
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 2754111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA202 8264Medicaid
OR039185Medicaid
WA202 8264Medicaid
ORR110890Medicare ID - Type Unspecified