Provider Demographics
NPI:1689847691
Name:MILES, JENNIFER L (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:MILES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61250 SE COOMBS PL
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3704
Mailing Address - Country:US
Mailing Address - Phone:541-706-5940
Mailing Address - Fax:541-706-5941
Practice Address - Street 1:61250 SE COOMBS PL
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3704
Practice Address - Country:US
Practice Address - Phone:541-706-5940
Practice Address - Fax:541-706-5941
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500713291Medicaid