Provider Demographics
NPI:1104406735
Name:DIES, JESSICA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:DIES
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 1:8443 NE HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-5532
Mailing Address - Country:US
Mailing Address - Phone:615-796-4666
Mailing Address - Fax:
Practice Address - Street 1:3835 SW 185TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97078-1553
Practice Address - Country:US
Practice Address - Phone:503-626-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25750225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist