Provider Demographics
NPI:1629289301
Name:WANG, REBECCA L JACKSON (MS PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L JACKSON
Last Name:WANG
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:LYNNE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS PT
Mailing Address - Street 1:2241 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:OR
Mailing Address - Zip Code:97071-2811
Mailing Address - Country:US
Mailing Address - Phone:503-982-8544
Mailing Address - Fax:
Practice Address - Street 1:2241 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-2811
Practice Address - Country:US
Practice Address - Phone:503-982-8544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR04502225100000X
WAPT00008445225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR181491Medicaid
824151013OtherBLUE CROSS BLUE SHIELD
P00070573Medicare ID - Type UnspecifiedRAILROAD MEDICARE
824151013OtherBLUE CROSS BLUE SHIELD
WAAB33962Medicare ID - Type UnspecifiedMEDICARE B