Provider Demographics
NPI:1558636530
Name:LEONARD, JENNIFER S (LMT)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:S
Last Name:LEONARD
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 1:4925 SW JAMIESON RD
Mailing Address - Street 2:21
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3558
Mailing Address - Country:US
Mailing Address - Phone:503-201-7110
Mailing Address - Fax:
Practice Address - Street 1:2207 NE BROADWAY ST
Practice Address - Street 2:123
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1693
Practice Address - Country:US
Practice Address - Phone:503-201-7110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16547225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist