Healthcare Provider Details

I. General information

NPI: 1336009836
Provider Name (Legal Business Name): JUSTIN MICHAEL PENNINGTON DPT, PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MCNARY ESTATES DR N
KEIZER OR
97303-7459
US

IV. Provider business mailing address

2313 PARK AVE APT 1
NORWOOD OH
45212-3309
US

V. Phone/Fax

Practice location:
  • Phone: 503-463-5231
  • Fax: 503-463-5175
Mailing address:
  • Phone: 276-206-7454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT022122
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number16878
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP056203T
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: