Provider Demographics
NPI:1730441171
Name:GLISSON, JESSICA (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GLISSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GLISSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:1426 SE 25TH AVE
Mailing Address - Street 2:APT 5
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3966
Mailing Address - Country:US
Mailing Address - Phone:503-348-9774
Mailing Address - Fax:
Practice Address - Street 1:107 SE WASHINGTON ST
Practice Address - Street 2:SUITE#134
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2103
Practice Address - Country:US
Practice Address - Phone:503-236-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18512225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist