Provider Demographics
NPI:1669919981
Name:SLATER, JESSE TRISTAN (AAS)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:TRISTAN
Last Name:SLATER
Suffix:
Gender:M
Credentials:AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18973 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-7917
Mailing Address - Country:US
Mailing Address - Phone:541-280-7234
Mailing Address - Fax:
Practice Address - Street 1:816 NW HILL ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2925
Practice Address - Country:US
Practice Address - Phone:541-280-7234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22002225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist