Provider Demographics
NPI:1013939511
Name:PORT, JANA LYNN (PTA)
Entity Type:Individual
Prefix:MS
First Name:JANA
Middle Name:LYNN
Last Name:PORT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4920 NE GLISAN ST
Mailing Address - Street 2:#416
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2963
Mailing Address - Country:US
Mailing Address - Phone:503-239-7523
Mailing Address - Fax:
Practice Address - Street 1:11300 NE HALSEY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-2096
Practice Address - Country:US
Practice Address - Phone:503-257-9881
Practice Address - Fax:503-257-8964
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR7673225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant