Healthcare Provider Details

I. General information

NPI: 1720916422
Provider Name (Legal Business Name): JAKE TRIANCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61470 S HWY 97 STE B
BEND OR
97702-2559
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 541-508-5473
  • Fax: 541-508-5474
Mailing address:
  • Phone: 726-202-3039
  • Fax: 210-978-5592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number66075
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: