Provider Demographics
NPI:1265930374
Name:ERICKSON, MOLLY JANEZICH (LAC)
Entity type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:JANEZICH
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 NW 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2463
Mailing Address - Country:US
Mailing Address - Phone:612-232-6896
Mailing Address - Fax:612-232-6896
Practice Address - Street 1:2455 NW MARSHALL ST STE 7B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2949
Practice Address - Country:US
Practice Address - Phone:503-597-8719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC184722171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist