Provider Demographics
NPI:1447853213
Name:COSTANZO, JAYMI
Entity type:Individual
Prefix:
First Name:JAYMI
Middle Name:
Last Name:COSTANZO
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 1:1217 NE BURNSIDE RD STE 301
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-5705
Mailing Address - Country:US
Mailing Address - Phone:503-492-2625
Mailing Address - Fax:
Practice Address - Street 1:1217 NE BURNSIDE RD STE 301
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5705
Practice Address - Country:US
Practice Address - Phone:503-492-2625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC201895171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist