Provider Demographics
NPI:1649478710
Name:RALSTON, JILL MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:RALSTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16057 NW GRAF ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-9213
Mailing Address - Country:US
Mailing Address - Phone:503-645-8434
Mailing Address - Fax:
Practice Address - Street 1:75 SHORE DR
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1125
Practice Address - Country:US
Practice Address - Phone:503-397-2720
Practice Address - Fax:503-397-2669
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029043Medicaid