Provider Demographics
NPI:1962757054
Name:FRECHETTE, JESSE (PT)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:FRECHETTE
Suffix:
Gender:M
Credentials:PT
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 1:3400 STATE ST
Practice Address - Street 2:STE. G-704
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5861
Practice Address - Country:US
Practice Address - Phone:503-378-7434
Practice Address - Fax:503-362-2703
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06911225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500647598Medicaid
ORR190771Medicare PIN
ORR173960Medicare PIN
ORR190082Medicare PIN
ORR189299Medicare PIN
ORR188070Medicare PIN
OR500647598Medicaid