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General NPI Number Information
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NPI Number | 1033528443
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Entity Type | Individual
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Provider Name | JENNIFER LUDTKE ATC
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Gender | Female
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Dates
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Enumeration Date | 08/11/2014
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Last Update Date | 01/24/2022
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Provider Practice Location Address
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Address Line | 5210 N KERBY AVE
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City | PORTLAND
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State | OR
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Zip | 97217-2699
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Country | US
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Telephone | 559-707-1953
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Fax |
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Provider Business Mailing Address
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Address Line | 1739 NE 47TH AVE
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City | PORTLAND
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State | OR
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Zip | 97213-2009
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Country | US
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Telephone | 559-707-1953
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT-AT-10206431
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000018517
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License Number State | CA
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