Provider Demographics
NPI:1912419177
Name:SWIM, JESSE THOMAS (LMT)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:THOMAS
Last Name:SWIM
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 NW 185TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-3492
Mailing Address - Country:US
Mailing Address - Phone:503-290-6636
Mailing Address - Fax:503-213-7100
Practice Address - Street 1:3220 NW 185TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-3492
Practice Address - Country:US
Practice Address - Phone:503-290-6636
Practice Address - Fax:503-213-7100
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23119225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist