Provider Demographics
NPI:1295278729
Name:WOLF, JONATHAN HETRICK (LMT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HETRICK
Last Name:WOLF
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5263 NE 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-4423
Mailing Address - Country:US
Mailing Address - Phone:503-915-9835
Mailing Address - Fax:
Practice Address - Street 1:5263 NE 16TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-4423
Practice Address - Country:US
Practice Address - Phone:503-915-9835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-01
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20541225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist