Provider Demographics
NPI:1891042784
Name:WYANT, JENNIFER L (LMT, CMMP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WYANT
Suffix:
Gender:F
Credentials:LMT, CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21131 S JUBB RD
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023-8629
Mailing Address - Country:US
Mailing Address - Phone:503-732-0011
Mailing Address - Fax:
Practice Address - Street 1:1224 SW MORRISON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2218
Practice Address - Country:US
Practice Address - Phone:503-732-0011
Practice Address - Fax:678-666-7128
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18843172M00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist