Provider Demographics
NPI:1043657331
Name:SMITH, KIMBERLY JAN (PT)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:JAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 NE BRAZEE ST
Mailing Address - Street 2:#1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4162
Mailing Address - Country:US
Mailing Address - Phone:503-280-1107
Mailing Address - Fax:
Practice Address - Street 1:909 NE BRAZEE ST
Practice Address - Street 2:#1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-4162
Practice Address - Country:US
Practice Address - Phone:503-280-1107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist