Provider Demographics
NPI:1851160667
Name:GRIZZARD, JANELLE EVETTE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JANELLE
Middle Name:EVETTE
Last Name:GRIZZARD
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 1:1453 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3800
Mailing Address - Country:US
Mailing Address - Phone:480-586-7859
Mailing Address - Fax:
Practice Address - Street 1:3821 NE MLK BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-1114
Practice Address - Country:US
Practice Address - Phone:480-586-7859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18608225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty