Provider Demographics
NPI:1487638250
Name:TOSTENRUD, JENNIFER LYNN RUSSELL (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN RUSSELL
Last Name:TOSTENRUD
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:10215 SW PARK WAY
Practice Address - Street 2:STE. D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5036
Practice Address - Country:US
Practice Address - Phone:503-292-3583
Practice Address - Fax:503-292-1022
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8717225100000X
WAPT00009657225100000X
ORPT 60671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1487638250Medicaid
WAP00393824OtherRR MEDICARE
WA8418055Medicaid
OR500679013Medicaid
WA8418055Medicaid
WAP00393824OtherRR MEDICARE
ORR177693Medicare PIN