Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 61646 | OR |
NPI | 1003262635 |
---|---|
Provider Name | Mr. Paul Emerson Jaques |
First Address | Corvallis, OR 97330-3745 |
Second Address | Corvallis, OR 97330-3495 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2016 |
Last Update Date | 12/05/2016 |