Provider Demographics
NPI:1205301975
Name:STIVERS, JACQUELINE ELIESA (ND LAC)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ELIESA
Last Name:STIVERS
Suffix:
Gender:F
Credentials:ND LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2318 NE MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3715
Mailing Address - Country:US
Mailing Address - Phone:503-539-6832
Mailing Address - Fax:
Practice Address - Street 1:2318 NE MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3715
Practice Address - Country:US
Practice Address - Phone:503-335-8611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
ORAC190894171100000X
OR4216208D00000X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty