Provider Demographics
NPI:1689657652
Name:JACKSON, AIMEE LEONA (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:LEONA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:AIMEE
Other - Middle Name:
Other - Last Name:GRIDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:10215 SW PARKWAY
Practice Address - Street 2:SUITE D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5036
Practice Address - Country:US
Practice Address - Phone:503-292-3583
Practice Address - Fax:503-292-1022
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR295706Medicaid
OR650015562OtherRR MEDICARE
OR104284Medicare PIN