Provider Demographics
NPI:1447420674
Name:FARLESS, JACQUELINE T (LMT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:T
Last Name:FARLESS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 714
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:OR
Mailing Address - Zip Code:97538-0714
Mailing Address - Country:US
Mailing Address - Phone:541-597-4749
Mailing Address - Fax:541-597-4749
Practice Address - Street 1:5616 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:OR
Practice Address - Zip Code:97538-9711
Practice Address - Country:US
Practice Address - Phone:541-659-9437
Practice Address - Fax:541-597-4749
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7399171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor