Provider Demographics
NPI:1750941241
Name:DAILEY, JENNIE
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:DAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-0658
Mailing Address - Country:US
Mailing Address - Phone:503-901-6494
Mailing Address - Fax:
Practice Address - Street 1:2305 SE WASHINGTON ST STE 105
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7647
Practice Address - Country:US
Practice Address - Phone:503-901-6494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023438173C00000X, 225700000X
CA75668173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist