Basic Information
| Provider Information | |||||||||
| NPI: | 1912565623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORREIA-JEFFERS | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11709 SW BEAVERTON HILLSDALE HWY STE B-6 | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970052992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9713274906 | ||||||||
| FaxNumber: | 5032124855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2019 | ||||||||
| LastUpdateDate: | 06/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.