Provider Demographics
NPI:1295710150
Name:MCHENRY, JEAN MARIE (PT)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIE
Last Name:MCHENRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JEAN
Other - Middle Name:MARIE
Other - Last Name:CANADAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1888
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-1888
Mailing Address - Country:US
Mailing Address - Phone:541-536-6122
Mailing Address - Fax:541-536-6123
Practice Address - Street 1:51681 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-9626
Practice Address - Country:US
Practice Address - Phone:541-536-6122
Practice Address - Fax:541-536-6123
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR024385Medicaid
OR24385Medicaid
OR386526Medicare ID - Type Unspecified
OR24385Medicaid