Provider Demographics
NPI:1831414747
Name:CHARTERS, JORDAN KIMBLE (LMT)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:KIMBLE
Last Name:CHARTERS
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 1:19350 SW MELNORE CT
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97006-2807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15850 NW CENTRAL DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-1101
Practice Address - Country:US
Practice Address - Phone:503-431-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16334225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist