Provider Demographics
NPI:1629617360
Name:BEKKER, HANNALISA GORDON-JOHNSON (LAC, MACOM)
Entity Type:Individual
Prefix:
First Name:HANNALISA
Middle Name:GORDON-JOHNSON
Last Name:BEKKER
Suffix:
Gender:F
Credentials:LAC, MACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 SE 84TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-1315
Mailing Address - Country:US
Mailing Address - Phone:541-543-1407
Mailing Address - Fax:
Practice Address - Street 1:215 SE 6TH ST STE 211
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2471
Practice Address - Country:US
Practice Address - Phone:541-543-1407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR196357171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist