Provider Demographics
NPI:1639359961
Name:MIRANDA, JESUS C (PT, DPT, OCS)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:C
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:J.
Other - Middle Name:CARLOS
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT, OCS
Mailing Address - Street 1:10151 SE SUNNYSIDE RD STE 310
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6913
Mailing Address - Country:US
Mailing Address - Phone:503-496-1058
Mailing Address - Fax:888-675-5282
Practice Address - Street 1:10151 SE SUNNYSIDE RD STE 310
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6913
Practice Address - Country:US
Practice Address - Phone:503-496-1058
Practice Address - Fax:888-675-5282
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-03
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR55472251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic