Provider Demographics
NPI:1215041363
Name:ROBERTS, JESSIE LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:LYNN
Last Name:ROBERTS
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 1:19146 S MOLALLA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-7167
Mailing Address - Country:US
Mailing Address - Phone:503-974-0048
Mailing Address - Fax:503-974-0069
Practice Address - Street 1:22695 S UPPER HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OR
Practice Address - Zip Code:97004-9732
Practice Address - Country:US
Practice Address - Phone:503-708-6941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR04620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR114556Medicare PIN
ORR144512Medicare PIN
ORR114778Medicare PIN
ORR114519Medicare PIN
ORR144511Medicare PIN
ORR143689Medicare PIN