Provider Demographics
NPI:1942954193
Name:NELSON, SIERRA JYL
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:JYL
Last Name:NELSON
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 1:15450 SE 93RD AVE
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-9602
Mailing Address - Country:US
Mailing Address - Phone:971-235-5561
Mailing Address - Fax:971-386-1281
Practice Address - Street 1:15480 SE 82ND DR STE B
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9633
Practice Address - Country:US
Practice Address - Phone:971-235-5561
Practice Address - Fax:971-386-1281
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist