Provider Demographics
NPI:1780097089
Name:WING, JEFFERY L (LMT)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:L
Last Name:WING
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6274 SW CAPITOL HWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2674
Mailing Address - Country:US
Mailing Address - Phone:503-709-2811
Mailing Address - Fax:
Practice Address - Street 1:6274 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2674
Practice Address - Country:US
Practice Address - Phone:503-709-2811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7695173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist