Provider Demographics
NPI:1013152958
Name:JANICKI, JUSTIN THOMAS (LAC, MACOM, DIPLOM)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:THOMAS
Last Name:JANICKI
Suffix:
Gender:M
Credentials:LAC, MACOM, DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 NE FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1735
Mailing Address - Country:US
Mailing Address - Phone:716-680-0636
Mailing Address - Fax:
Practice Address - Street 1:5230 NE FREMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1735
Practice Address - Country:US
Practice Address - Phone:716-680-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01233171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist