Provider Demographics
NPI:1750520755
Name:DODGE, JEANETTE ELIZABETH (LAC)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ELIZABETH
Last Name:DODGE
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 1:11575 SW PACIFIC HWY STE 147
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8671
Mailing Address - Country:US
Mailing Address - Phone:503-968-3124
Mailing Address - Fax:
Practice Address - Street 1:10900 SW NORTH DAKOTA ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-4121
Practice Address - Country:US
Practice Address - Phone:503-968-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00121171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist