Basic Information
Provider Information | |||||||||
NPI: | 1235113028 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DERIN | ||||||||
FirstName: | JEWEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEHMAN | ||||||||
OtherFirstName: | JEWEL | ||||||||
OtherMiddleName: | DERIN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 495 STATE ST | ||||||||
Address2: | FLOOR 6 | ||||||||
City: | SALEM | ||||||||
State: | OR | ||||||||
PostalCode: | 973013757 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034006110 | ||||||||
FaxNumber: | 5034007956 | ||||||||
Practice Location | |||||||||
Address1: | 111 W C ST | ||||||||
Address2: |   | ||||||||
City: | SILVERTON | ||||||||
State: | OR | ||||||||
PostalCode: | 973811458 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5038736111 | ||||||||
FaxNumber: | 5038736113 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2005 | ||||||||
LastUpdateDate: | 12/31/2013 | ||||||||
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 | 225100000X | 0915 | OR | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 040993 | 05 | OR |   | MEDICAID |