Basic Information
| Provider Information | |||||||||
| NPI: | 1487638250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOSTENRUD | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN RUSSELL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PHYSICAL THERAPIST | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSSELL | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| 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: | 10215 SW PARK WAY | ||||||||
| Address2: | STE. D | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972255036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032923583 | ||||||||
| FaxNumber: | 5032921022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 02/13/2015 | ||||||||
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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 | 8717 | CO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT00009657 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT 60671 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1487638250 | 05 | WA | MEDICAID | P00393824 | 01 | WA | RR MEDICARE | OTHER | 8418055 | 05 | WA | MEDICAID | 500679013 | 05 | OR | MEDICAID |