Provider Demographics
NPI:1629311865
Name:MARIE, JACQUELINE (LMT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MARIE
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 1:5408 SE 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-4148
Mailing Address - Country:US
Mailing Address - Phone:503-803-8352
Mailing Address - Fax:
Practice Address - Street 1:5408 SE 111TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-4148
Practice Address - Country:US
Practice Address - Phone:503-803-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3453247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other