Provider Demographics
NPI:1558559179
Name:SWANSON JAECKS, KELLI MARION (RDH)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARION
Last Name:SWANSON JAECKS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 JERRIS AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5278
Mailing Address - Country:US
Mailing Address - Phone:503-315-2222
Mailing Address - Fax:503-315-2248
Practice Address - Street 1:380 JERRIS AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5278
Practice Address - Country:US
Practice Address - Phone:503-315-2222
Practice Address - Fax:503-315-2248
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3590124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist