Basic Information
| Provider Information | |||||||||
| NPI: | 1104190552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 4242 COMMERCE ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974025418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414849632 | ||||||||
| FaxNumber: | 5414847466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 04/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 60259458 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | OR 61457 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0349710 | 01 | OR | WA L&I | OTHER | P01610736 | 01 | OR | RR MEDICARE | OTHER | 500696235 | 05 | OR | MEDICAID | P01338293 | 01 | WA | RR MEDICARE | OTHER |