Provider Demographics
NPI:1124486022
Name:NEWBERRY, JEFF NEIL (ID)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:NEIL
Last Name:NEWBERRY
Suffix:
Gender:M
Credentials:ID
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:NEIL
Other - Last Name:NEWBERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:25117 SW PARKWAY AVE
Mailing Address - Street 2:STE D
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:503-570-3665
Mailing Address - Fax:
Practice Address - Street 1:1957 ALVIN RICKEN DR
Practice Address - Street 2:C/O JEFF NEWBERRY
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2727
Practice Address - Country:US
Practice Address - Phone:208-235-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT-1826225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist