Provider Demographics
NPI:1316506777
Name:ROUSSEAU, JOCELYN LEE (LMT)
Entity type:Individual
Prefix:
First Name:JOCELYN
Middle Name:LEE
Last Name:ROUSSEAU
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:PO BOX 1916
Mailing Address - Street 2:
Mailing Address - City:CAVE JUNCTION
Mailing Address - State:OR
Mailing Address - Zip Code:97523-1916
Mailing Address - Country:US
Mailing Address - Phone:541-415-4395
Mailing Address - Fax:
Practice Address - Street 1:315A CAVES HWY
Practice Address - Street 2:
Practice Address - City:CAVE JUNCTION
Practice Address - State:OR
Practice Address - Zip Code:97523-9604
Practice Address - Country:US
Practice Address - Phone:541-415-4395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24095225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist