Provider Demographics
NPI:1275993123
Name:MARSH, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MARSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-4802
Mailing Address - Country:US
Mailing Address - Phone:541-265-5356
Mailing Address - Fax:
Practice Address - Street 1:835 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4802
Practice Address - Country:US
Practice Address - Phone:541-265-5356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6116225100000X
AZ2253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist