Provider Demographics
NPI:1033847025
Name:EDMONDS, JENNIFER LYN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYN
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7318 N SYRACUSE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5068
Mailing Address - Country:US
Mailing Address - Phone:206-930-8246
Mailing Address - Fax:
Practice Address - Street 1:812 SE 48TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1724
Practice Address - Country:US
Practice Address - Phone:503-236-2624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08638225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant