Provider Demographics
NPI:1124745500
Name:WEST PORTLAND THERAPEUTIC MASSAGE LLC
Entity type:Organization
Organization Name:WEST PORTLAND THERAPEUTIC MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-320-6305
Mailing Address - Street 1:7720 S MACADAM AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3000
Mailing Address - Country:US
Mailing Address - Phone:503-320-6305
Mailing Address - Fax:
Practice Address - Street 1:9045 SW BARBUR BLVD STE 109
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-4027
Practice Address - Country:US
Practice Address - Phone:503-662-8098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty