Provider Demographics
NPI:1235113028
Name:DERIN, JEWEL (PT)
Entity Type:Individual
Prefix:
First Name:JEWEL
Middle Name:
Last Name:DERIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JEWEL
Other - Middle Name:DERIN
Other - Last Name:LEHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:495 STATE ST
Mailing Address - Street 2:FLOOR 6
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3757
Mailing Address - Country:US
Mailing Address - Phone:503-400-6110
Mailing Address - Fax:503-400-7956
Practice Address - Street 1:111 W C ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1458
Practice Address - Country:US
Practice Address - Phone:503-873-6111
Practice Address - Fax:503-873-6113
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0915225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR040993Medicaid
ROOWCXBSBMedicare ID - Type Unspecified