Provider Demographics
NPI:1609903467
Name:SMITH, JOLEEN LOUISE (LMT, CST)
Entity Type:Individual
Prefix:
First Name:JOLEEN
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 N. RIVERSIDE AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501
Mailing Address - Country:US
Mailing Address - Phone:541-660-0033
Mailing Address - Fax:541-479-3524
Practice Address - Street 1:1017 N. RIVERSIDE AVE STE 115
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-660-0033
Practice Address - Fax:541-479-3524
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12213225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR20-4812656OtherEIN