Provider Demographics
NPI:1821471087
Name:PICKERING, JOHN PHILLIP (MS-SLP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILLIP
Last Name:PICKERING
Suffix:
Gender:M
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15532 SW PACIFIC HWY # 133
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3598
Mailing Address - Country:US
Mailing Address - Phone:503-816-3508
Mailing Address - Fax:
Practice Address - Street 1:572 N 11TH ST
Practice Address - Street 2:
Practice Address - City:AUMSVILLE
Practice Address - State:OR
Practice Address - Zip Code:97325-9578
Practice Address - Country:US
Practice Address - Phone:503-749-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15250235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist