Healthcare Provider Details

I. General information

NPI: 1982765236
Provider Name (Legal Business Name): JILL PREVENDAR PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 NE 139TH ST
VANCOUVER WA
98686-2742
US

IV. Provider business mailing address

2211 NE 139TH ST
VANCOUVER WA
98686-2742
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-3879
  • Fax: 503-413-4379
Mailing address:
  • Phone: 503-413-3879
  • Fax: 503-413-4379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00007744
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3727
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: