Provider Demographics
NPI:1053720813
Name:WATKINS, JESSICA LEIGH (LMP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:WATKINS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 NE 144TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-4117
Mailing Address - Country:US
Mailing Address - Phone:971-275-6761
Mailing Address - Fax:
Practice Address - Street 1:3401 SE 192ND AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683
Practice Address - Country:US
Practice Address - Phone:360-882-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021620225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist