Basic Information
| Provider Information | |||||||||
| NPI: | 1770637423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | JODY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 N PROCYON PL | ||||||||
| Address2: | |||||||||
| City: | STAR | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082867235 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4560 SE INTERNATIONAL WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712065129 | ||||||||
| FaxNumber: | 9712065209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT260 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.