Provider Demographics
NPI:1306124219
Name:MCCOLL, JUNETTE E (LMT, CA)
Entity type:Individual
Prefix:
First Name:JUNETTE
Middle Name:E
Last Name:MCCOLL
Suffix:
Gender:F
Credentials:LMT, CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 NE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7511
Mailing Address - Country:US
Mailing Address - Phone:503-666-4531
Mailing Address - Fax:503-665-9997
Practice Address - Street 1:790 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7616
Practice Address - Country:US
Practice Address - Phone:503-618-0147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8270225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist