Basic Information
| Provider Information | |||||||||
| NPI: | 1003890039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOREPTA | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | SPEECH THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11481 SW HALL BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5034431402 | ||||||||
| Practice Location | |||||||||
| Address1: | 1315 NW 4TH ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419237494 | ||||||||
| FaxNumber: | 5415049153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11215 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 227946 | 05 | OR | MEDICAID |