Provider Demographics
NPI:1932823788
Name:LUSK, JENNIFER J (RDH, EPDH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:LUSK
Suffix:
Gender:F
Credentials:RDH, EPDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22337 SW FISK TER
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8059
Mailing Address - Country:US
Mailing Address - Phone:360-790-2054
Mailing Address - Fax:
Practice Address - Street 1:222 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4218
Practice Address - Country:US
Practice Address - Phone:503-352-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH7769124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist