Provider Demographics
NPI:1215273412
Name:MCGUIRE, JESSICA (PT, DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCGUIRE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1600 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4257
Mailing Address - Country:US
Mailing Address - Phone:503-540-6300
Mailing Address - Fax:
Practice Address - Street 1:1600 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4257
Practice Address - Country:US
Practice Address - Phone:503-540-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPT60821225100000X
WAPT60291804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500679921Medicaid
ORPT60821OtherLICENSE
ORR178786Medicare PIN