Provider Demographics
NPI:1457669251
Name:HINCKLEY, JANIECE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:JANIECE
Middle Name:MARIE
Last Name:HINCKLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3009
Mailing Address - Country:US
Mailing Address - Phone:503-221-3429
Mailing Address - Fax:503-294-3240
Practice Address - Street 1:3101 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3009
Practice Address - Country:US
Practice Address - Phone:503-221-3429
Practice Address - Fax:503-294-3240
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3870Medicaid