Provider Demographics
NPI:1841694312
Name:JONES, MIRIAM R (LMT)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:R
Last Name:JONES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:R
Other - Last Name:OSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1716 SE 92ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-1931
Mailing Address - Country:US
Mailing Address - Phone:503-577-7127
Mailing Address - Fax:
Practice Address - Street 1:45 82ND DR STE 45
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2562
Practice Address - Country:US
Practice Address - Phone:503-577-7388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17680225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist