Provider Demographics
NPI:1780834200
Name:KJELLGREN, SARA JEAN (LMT)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:JEAN
Last Name:KJELLGREN
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 1:32977 SAND RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-9266
Mailing Address - Country:US
Mailing Address - Phone:541-258-1604
Mailing Address - Fax:
Practice Address - Street 1:2225 S MAIN RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2482
Practice Address - Country:US
Practice Address - Phone:541-258-1983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist