Provider Demographics
NPI:1184898694
Name:GARDNER, JESSICA AMY (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:AMY
Last Name:GARDNER
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 1:3944 N MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1163
Mailing Address - Country:US
Mailing Address - Phone:503-517-8222
Mailing Address - Fax:503-517-8223
Practice Address - Street 1:3944 N MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1163
Practice Address - Country:US
Practice Address - Phone:503-517-8222
Practice Address - Fax:503-517-8223
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13866172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist