Provider Demographics
NPI:1194497271
Name:PIERCE, JONATHAN (BCSI LMT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:PIERCE
Suffix:
Gender:M
Credentials:BCSI LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 NE 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5705
Mailing Address - Country:US
Mailing Address - Phone:480-438-6110
Mailing Address - Fax:
Practice Address - Street 1:1411 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1485
Practice Address - Country:US
Practice Address - Phone:480-438-6110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26338225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist