Provider Demographics
NPI:1568052595
Name:CARROLL, JAMISON KEITH (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:JAMISON
Middle Name:KEITH
Last Name:CARROLL
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11683 SW TEAL BLVD APT M
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-7969
Mailing Address - Country:US
Mailing Address - Phone:435-213-6134
Mailing Address - Fax:
Practice Address - Street 1:9370 SW GREENBURG RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5442
Practice Address - Country:US
Practice Address - Phone:503-200-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-23
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR447328225X00000X
AZOTH-008360225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1568052595Medicaid