Provider Demographics
NPI:1770551244
Name:KWON, JACQUELYN SOYOUNG (MPT)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:SOYOUNG
Last Name:KWON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:SOYOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:815 NW 9TH ST
Mailing Address - Street 2:SUITE180
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-6173
Mailing Address - Country:US
Mailing Address - Phone:541-768-5157
Mailing Address - Fax:541-768-5080
Practice Address - Street 1:815 NW 9TH ST
Practice Address - Street 2:SUITE180
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6173
Practice Address - Country:US
Practice Address - Phone:541-768-5157
Practice Address - Fax:541-768-5080
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5144225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist