Provider Demographics
NPI:1770827693
Name:EFSEAFF, JEREMY DANIEL (LMT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DANIEL
Last Name:EFSEAFF
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 RIDGEPOINT ST NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-1778
Mailing Address - Country:US
Mailing Address - Phone:503-930-0706
Mailing Address - Fax:
Practice Address - Street 1:5300 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4428
Practice Address - Country:US
Practice Address - Phone:503-393-3624
Practice Address - Fax:503-393-0108
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17482225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist