Provider Demographics
NPI:1205314580
Name:HANEY, JILLIAN (DPT)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:HANEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:JILLIAN
Other - Middle Name:
Other - Last Name:HANEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:516 SE 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10330 SE 32ND AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6587
Practice Address - Country:US
Practice Address - Phone:503-513-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR11320996900OtherPROVIDENCE HEALTH PLAN