1689657652 NPI number — AIMEE LEONA JACKSON PHYSICAL THERAPIST

Table of content: AIMEE LEONA JACKSON PHYSICAL THERAPIST (NPI 1689657652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689657652 NPI number — AIMEE LEONA JACKSON PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
AIMEE
Provider Middle Name:
LEONA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRIDLEY
Provider Other First Name:
AIMEE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689657652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16083 SW UPPER BOONES FERRY RD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97224-7736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:
503-639-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10215 SW PARKWAY
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225-5036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-292-3583
Provider Business Practice Location Address Fax Number:
503-292-1022
Provider Enumeration Date:
11/23/2005

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:  3632 , 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)

  • Identifier: 295706 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 650015562 . This is a "RR MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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