Provider Demographics
NPI:1326593112
Name:SHIYOMURA, JESSICA HOPE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:HOPE
Last Name:SHIYOMURA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:HOPE
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:13590 NW MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BANKS
Mailing Address - State:OR
Mailing Address - Zip Code:97106
Mailing Address - Country:US
Mailing Address - Phone:971-713-3960
Mailing Address - Fax:971-713-3966
Practice Address - Street 1:13590 NW MAIN STREET
Practice Address - Street 2:
Practice Address - City:BANKS
Practice Address - State:OR
Practice Address - Zip Code:97106
Practice Address - Country:US
Practice Address - Phone:971-713-3960
Practice Address - Fax:971-713-3966
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR861165534Medicaid