Provider Demographics
NPI:1083167951
Name:MCCONAHAY, JESSICA (DPT)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:MCCONAHAY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:1307 NE 102ND AVE
Practice Address - Street 2:SUITE G
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3980
Practice Address - Country:US
Practice Address - Phone:503-253-0924
Practice Address - Fax:503-256-5469
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR61838225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01767083OtherRR MEDICARE
OR500715462Medicaid
ORP01767083OtherRR MEDICARE
ORR190759Medicare PIN