Provider Demographics
NPI:1699198267
Name:CARNEOL, JESSICA SPYDER (LMT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SPYDER
Last Name:CARNEOL
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 1:3432 SE GRANT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5732
Mailing Address - Country:US
Mailing Address - Phone:608-516-2142
Mailing Address - Fax:
Practice Address - Street 1:3432 SE GRANT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5732
Practice Address - Country:US
Practice Address - Phone:608-516-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-01
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19774225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist