Provider Demographics
NPI:1952508996
Name:SMITH-BLOCKLEY, JESSICA (PT)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:SMITH-BLOCKLEY
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 1:16083 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:503-443-6156
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:837 SW FIRST AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-3307
Practice Address - Country:US
Practice Address - Phone:503-450-0591
Practice Address - Fax:503-450-0867
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2230225100000X
OR6497225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808225200Medicaid
ORR195724OtherMEDICARE
ID1952508996-000Medicaid
ID1952508996Medicaid
OR500635041Medicaid
ID1952508996-000Medicaid
ORR161534Medicare PIN
ID1650038Medicare PIN
ID1952508996Medicaid