Provider Demographics
NPI:1902253008
Name:TITAN PHYSICAL THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:TITAN PHYSICAL THERAPY SERVICES, LLC
Other - Org Name:PHYSICAL THERAPY AT THE MAC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:503-519-0011
Mailing Address - Street 1:16623 SW OYSTERCATCHER LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-8706
Mailing Address - Country:US
Mailing Address - Phone:503-519-0011
Mailing Address - Fax:503-590-3687
Practice Address - Street 1:1849 SW SALMON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1726
Practice Address - Country:US
Practice Address - Phone:503-519-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06984261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy