Provider Demographics
NPI:1821323973
Name:WALLING, JASMINE LORRAINE (LMT)
Entity Type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:LORRAINE
Last Name:WALLING
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 1:25700 SW ARGYLE AVE
Mailing Address - Street 2:UNIT C
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-5799
Mailing Address - Country:US
Mailing Address - Phone:503-582-9805
Mailing Address - Fax:503-582-9795
Practice Address - Street 1:25700 SW ARGYLE AVE
Practice Address - Street 2:UNIT C
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-5799
Practice Address - Country:US
Practice Address - Phone:503-582-9805
Practice Address - Fax:503-582-9795
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16668225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR16668OtherSTATE LICENSE