Provider Demographics
NPI:1386283224
Name:GULLOTTO, JENIFER LYN (ND)
Entity type:Individual
Prefix:DR
First Name:JENIFER
Middle Name:LYN
Last Name:GULLOTTO
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SW VISTA AVE APT 707
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1137
Mailing Address - Country:US
Mailing Address - Phone:559-827-3003
Mailing Address - Fax:
Practice Address - Street 1:17084 PILKINGTON RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5352
Practice Address - Country:US
Practice Address - Phone:503-303-5472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4294175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath