Provider Demographics
NPI:1104241025
Name:MANDZUK, JENNA (LAC)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MANDZUK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20845 SW EDY RD
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8616
Mailing Address - Country:US
Mailing Address - Phone:971-340-0073
Mailing Address - Fax:
Practice Address - Street 1:20508 SW ROY ROGERS RD STE 145
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9931
Practice Address - Country:US
Practice Address - Phone:971-340-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC165564171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist