Basic Information
| Provider Information | |||||||||
| NPI: | 1780984898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOORN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | PAIGE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LONG | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | PAIGE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065200 | ||||||||
| FaxNumber: | 9712065203 | ||||||||
| Practice Location | |||||||||
| Address1: | 20420 MARINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | STANWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606527585 | ||||||||
| FaxNumber: | 3606524594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2010 | ||||||||
| LastUpdateDate: | 10/25/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | P160043778 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.