Provider Demographics
NPI:1275979007
Name:ENG, JONATHAN DAVID (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:ENG
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 1:3521 SW COMUS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7561
Mailing Address - Country:US
Mailing Address - Phone:202-744-7693
Mailing Address - Fax:503-966-1459
Practice Address - Street 1:1001 SE WATER AVE STE 460
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2178
Practice Address - Country:US
Practice Address - Phone:971-303-2740
Practice Address - Fax:503-966-1459
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60196225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500657096Medicaid
R170292Medicare PIN