Provider Demographics
NPI:1104279298
Name:FALK, JENNIFER JILL (LMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JILL
Last Name:FALK
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 1:1416 SE 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3537
Mailing Address - Country:US
Mailing Address - Phone:503-314-9297
Mailing Address - Fax:971-312-2195
Practice Address - Street 1:1416 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3537
Practice Address - Country:US
Practice Address - Phone:503-314-9297
Practice Address - Fax:971-312-2195
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist