Provider Demographics
NPI:1699518142
Name:COCKRELL, MADISON JOHANNA (DPT)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:JOHANNA
Last Name:COCKRELL
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 NE HOOD AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7450
Mailing Address - Country:US
Mailing Address - Phone:503-666-1333
Mailing Address - Fax:
Practice Address - Street 1:304 NE HOOD AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7450
Practice Address - Country:US
Practice Address - Phone:503-666-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR65297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist