Provider Demographics
NPI:1376527424
Name:WOOD, JEFFERY (MS, PT)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 NW HAWTHORNE AVE
Mailing Address - Street 2:#103
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1257
Mailing Address - Country:US
Mailing Address - Phone:541-476-2502
Mailing Address - Fax:541-476-2397
Practice Address - Street 1:1701 NW HAWTHORNE AVE
Practice Address - Street 2:#103
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1257
Practice Address - Country:US
Practice Address - Phone:541-476-2502
Practice Address - Fax:541-476-2397
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2237225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116582Medicaid
ORR102084Medicare PIN
ORS60957Medicare UPIN