Provider Demographics
NPI:1255809919
Name:SULLIVAN, JANE SYLVIA
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:SYLVIA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 N BEECH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1115
Mailing Address - Country:US
Mailing Address - Phone:503-481-3964
Mailing Address - Fax:
Practice Address - Street 1:909 N BEECH ST STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1115
Practice Address - Country:US
Practice Address - Phone:503-481-3964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-10
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist