Basic Information
| Provider Information | |||||||||
| NPI: | 1003154840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAVEN | ||||||||
| FirstName: | JASMINE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 762 | ||||||||
| Address2: | |||||||||
| City: | WARRENTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971460762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034688703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1230 MARINE DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971034061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034688703 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2013 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 16697 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.