Provider Demographics
NPI:1902251168
Name:REGIS, JACLYN R (LMT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:R
Last Name:REGIS
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 1:2212 SE NORDLUND CT
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-6164
Mailing Address - Country:US
Mailing Address - Phone:971-336-5134
Mailing Address - Fax:
Practice Address - Street 1:12750 SW 2ND ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2778
Practice Address - Country:US
Practice Address - Phone:971-336-5134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR222313225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist