Provider Demographics
NPI:1548914468
Name:WIESERT, JENNIFER NORITA (LMT)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NORITA
Last Name:WIESERT
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 1:4239 NE 79TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-4203
Mailing Address - Country:US
Mailing Address - Phone:458-205-4126
Mailing Address - Fax:
Practice Address - Street 1:4239 NE 79TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-4203
Practice Address - Country:US
Practice Address - Phone:458-205-4126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26213225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR454500222Medicaid