Provider Demographics
NPI:1063243582
Name:LISIESKI, SAMUEL JACKSON (LMT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JACKSON
Last Name:LISIESKI
Suffix:
Gender:X
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 NE 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-6339
Mailing Address - Country:US
Mailing Address - Phone:512-230-7416
Mailing Address - Fax:
Practice Address - Street 1:7925 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-2341
Practice Address - Country:US
Practice Address - Phone:503-785-9914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR28282225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist