Provider Demographics
NPI:1497526222
Name:WILD, JEB RILEY (DPT)
Entity Type:Individual
Prefix:MR
First Name:JEB
Middle Name:RILEY
Last Name:WILD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SW COLUMBIA ST APT 1502
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5887
Mailing Address - Country:US
Mailing Address - Phone:772-971-1144
Mailing Address - Fax:
Practice Address - Street 1:24076 SE STARK ST STE 200
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3376
Practice Address - Country:US
Practice Address - Phone:503-491-1666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR65159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist