Provider Demographics
NPI:1306285028
Name:SCOTT, KELLI JO (LAC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:JO
Last Name:SCOTT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3028 SE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15691 SE ROYER RD
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:OR
Practice Address - Zip Code:97089-2642
Practice Address - Country:US
Practice Address - Phone:503-658-7715
Practice Address - Fax:503-658-7181
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-15
Last Update Date:2013-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3109124Q00000X
OR160456171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No124Q00000XDental ProvidersDental Hygienist