Provider Demographics
NPI:1942442207
Name:GRIMES, JENNIFER LEE (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:GRIMES
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 1:2385 NW WESTOVER RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3524
Mailing Address - Country:US
Mailing Address - Phone:503-715-7237
Mailing Address - Fax:503-715-0496
Practice Address - Street 1:2385 NW WESTOVER RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3524
Practice Address - Country:US
Practice Address - Phone:503-715-7237
Practice Address - Fax:503-715-0496
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60083922225100000X
OR05870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist