Provider Demographics
NPI:1578822706
Name:DAVENPORT, CATHY ANN (LMT)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:ANN
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:CATHY
Other - Middle Name:ANN
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 1212
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-1212
Mailing Address - Country:US
Mailing Address - Phone:971-237-2986
Mailing Address - Fax:
Practice Address - Street 1:1295 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3007
Practice Address - Country:US
Practice Address - Phone:503-763-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist