Provider Demographics
NPI:1093778680
Name:IVY, JERRY CLIFTON (PT)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:CLIFTON
Last Name:IVY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 355
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-0355
Mailing Address - Country:US
Mailing Address - Phone:541-426-4870
Mailing Address - Fax:541-426-4872
Practice Address - Street 1:4 S MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:JOSEPH
Practice Address - State:OR
Practice Address - Zip Code:97846-8434
Practice Address - Country:US
Practice Address - Phone:541-432-1480
Practice Address - Fax:541-432-1481
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2125225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR016852Medicaid
OR016852Medicaid