Provider Demographics
NPI:1639166432
Name:AINSWORTH, JEREMY M (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:M
Last Name:AINSWORTH
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12698 KINGS VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361-9551
Mailing Address - Country:US
Mailing Address - Phone:503-606-2077
Mailing Address - Fax:
Practice Address - Street 1:221 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:OR
Practice Address - Zip Code:97361-2240
Practice Address - Country:US
Practice Address - Phone:503-838-4244
Practice Address - Fax:503-838-4442
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-10000922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer