Provider Demographics
NPI:1982895330
Name:KAY, JACQUELYNNE M (LMT)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELYNNE
Middle Name:M
Last Name:KAY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 SE WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2159
Mailing Address - Country:US
Mailing Address - Phone:971-998-8193
Mailing Address - Fax:
Practice Address - Street 1:2024 SE CLINTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2245
Practice Address - Country:US
Practice Address - Phone:503-238-6262
Practice Address - Fax:503-473-8047
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12045174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist