Provider Demographics
NPI:1336539766
Name:PRENTISS, JESSE ZELINE (LMT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:ZELINE
Last Name:PRENTISS
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 1:630 JACOBSEN GULCH RD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-8527
Mailing Address - Country:US
Mailing Address - Phone:541-889-1164
Mailing Address - Fax:
Practice Address - Street 1:630 JACOBSEN GULCH RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-8527
Practice Address - Country:US
Practice Address - Phone:541-889-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11431225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist