1043641640 NPI number — JAY B JENSEN PT, ATC

Table of content: JAY B JENSEN PT, ATC (NPI 1043641640)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043641640 NPI number — JAY B JENSEN PT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENSEN
Provider First Name:
JAY
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043641640
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14925 SW BARROWS ROAD, STE 109, BOX 151
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-481-2973
Provider Business Mailing Address Fax Number:
503-590-3687

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1849 SW SALMON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97205-1726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-272-8785
Provider Business Practice Location Address Fax Number:
503-590-3687
Provider Enumeration Date:
12/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  06984 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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