Provider Demographics
NPI:1497185193
Name:VAN DEN BOOGAARD, JON BURTON
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:BURTON
Last Name:VAN DEN BOOGAARD
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:735 SW 158TH AVE
Practice Address - Street 2:SUITE 160
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4952
Practice Address - Country:US
Practice Address - Phone:503-597-0035
Practice Address - Fax:503-726-5490
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR60433225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist