Provider Demographics
NPI:1225649205
Name:GAMBOA, JACLYN (PT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:
Other - Last Name:SILVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:983 SW 25TH LN
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1325
Mailing Address - Country:US
Mailing Address - Phone:541-350-1277
Mailing Address - Fax:
Practice Address - Street 1:2600 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6337
Practice Address - Country:US
Practice Address - Phone:541-706-6843
Practice Address - Fax:541-598-3444
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics