Provider Demographics
NPI:1891242871
Name:CLAUSEN, JESSIE (PTA)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:CLAUSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12705 VILLAGE LOOP RD
Mailing Address - Street 2:
Mailing Address - City:SWISSHOME
Mailing Address - State:OR
Mailing Address - Zip Code:97480
Mailing Address - Country:US
Mailing Address - Phone:541-297-2705
Mailing Address - Fax:
Practice Address - Street 1:88267 TERRITORIAL RD
Practice Address - Street 2:SUITE 10A
Practice Address - City:VENETA
Practice Address - State:OR
Practice Address - Zip Code:97487-9499
Practice Address - Country:US
Practice Address - Phone:541-935-0761
Practice Address - Fax:541-935-0536
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09361225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant