Healthcare Provider Details

I. General information

NPI: 1003890039
Provider Name (Legal Business Name): JODY LYNN KOREPTA SPEECH THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 NW 4TH ST SUITE B
REDMOND OR
97756-1328
US

IV. Provider business mailing address

11481 SW HALL BLVD SUITE 201
PORTLAND OR
97223-8403
US

V. Phone/Fax

Practice location:
  • Phone: 541-923-7494
  • Fax: 541-504-9153
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-443-1402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11215
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: