Healthcare Provider Details

I. General information

NPI: 1700961851
Provider Name (Legal Business Name): DENISE COLETTE JEROME P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SW EMKAY DR STE 100
BEND OR
97702-3663
US

IV. Provider business mailing address

1001 SW EMKAY DR STE 100
BEND OR
97702-3663
US

V. Phone/Fax

Practice location:
  • Phone: 541-385-3344
  • Fax: 541-312-5256
Mailing address:
  • Phone: 541-385-3344
  • Fax: 541-312-5256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number63611
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1607
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierPT1607
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer
# 2
Identifier1972643138
Identifier TypeOTHER
Identifier StateAK
Identifier IssuerNPI # EQUINOX,INC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: