Provider Demographics
NPI:1396496998
Name:BEAUREGARD, JILL KATHERINE
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:KATHERINE
Last Name:BEAUREGARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6003 SE 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4567
Mailing Address - Country:US
Mailing Address - Phone:971-978-1268
Mailing Address - Fax:
Practice Address - Street 1:6003 SE 136TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-4567
Practice Address - Country:US
Practice Address - Phone:971-978-1268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR465900224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant