Provider Demographics
NPI:1235538711
Name:KEARSLEY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KEARSLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CAMPO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
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 1:51577 COLUMBIA RIVER HWY STE A
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-8409
Practice Address - Country:US
Practice Address - Phone:503-543-0254
Practice Address - Fax:503-543-0259
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0330024OtherWA L&I
OR500675880Medicaid
OR0330029OtherWA L&I
ORP01457340OtherRR MEDICARE PTAN
OR500675880Medicaid