Provider Demographics
NPI:1194510958
Name:CHURCHILL DICKS, JAEDON (LMT)
Entity type:Individual
Prefix:
First Name:JAEDON
Middle Name:
Last Name:CHURCHILL DICKS
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8222 N EDISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4912
Mailing Address - Country:US
Mailing Address - Phone:541-728-6867
Mailing Address - Fax:
Practice Address - Street 1:7318 N LEAVITT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4840
Practice Address - Country:US
Practice Address - Phone:503-567-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist