Provider Demographics
NPI:1043466493
Name:OLIVER, JENNIFER ANN (LPTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:OLIVER
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 ROCKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-4146
Mailing Address - Country:US
Mailing Address - Phone:503-534-2761
Mailing Address - Fax:
Practice Address - Street 1:12441 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1053
Practice Address - Country:US
Practice Address - Phone:503-255-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8004225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8004Medicaid
OR8004Medicare PIN
OR8004Medicaid