Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225700000X | Massage Therapist | 12783 | OR |
Y | 225700000X | Massage Therapist | MA 60378603 | WA |
NPI | 1013230309 |
---|---|
Provider Name | Jeane Gump |
First Address | Vancouver, WA 98664-2541 |
Second Address | Vancouver, WA 98664-2541 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/03/2010 |
Last Update Date | 06/03/2014 |