Basic Information
| Provider Information | |||||||||
| NPI: | 1225346570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | JANELLE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11481 SW HALL BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5036399699 | ||||||||
| Practice Location | |||||||||
| Address1: | 5955 SHOREVIEW LN N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973033981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034634221 | ||||||||
| FaxNumber: | 5034634522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2010 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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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 | 6280 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00991058 | 01 | OR | RR MEDICARE | OTHER | 500630480 | 05 | OR | MEDICAID |