Provider Demographics
NPI:1689791394
Name:SHACKELFORD, JAMIE DAWN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:DAWN
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:DAWN
Other - Last Name:CORNWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:13599 SW PACIFIC HWY STE. G
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:59102-6257
Mailing Address - Country:US
Mailing Address - Phone:503-481-5832
Mailing Address - Fax:503-481-5832
Practice Address - Street 1:13599 SW PACIFIC HWY STE G
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-4801
Practice Address - Country:US
Practice Address - Phone:503-481-5832
Practice Address - Fax:503-481-5832
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11791171W00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171W00000XOther Service ProvidersContractor