Provider Demographics
NPI:1487067005
Name:ACKERMAN, JERROD
Entity type:Individual
Prefix:
First Name:JERROD
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:390 E PARKCENTER BLVD
Practice Address - Street 2:STE. 130
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6662
Practice Address - Country:US
Practice Address - Phone:208-433-9211
Practice Address - Fax:208-433-9241
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0327602OtherWA L&I
ID0327604OtherWA L&I
ID1487067005Medicaid
ID0330328OtherWA L&I
ID0327611OtherWA L&I
ID0327610OtherWA L&I
ID0327602OtherWA L&I