Provider Demographics
NPI:1003890039
Name:KOREPTA, JODY LYNN (SPEECH THERAPIST)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LYNN
Last Name:KOREPTA
Suffix:
Gender:F
Credentials:SPEECH THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:1315 NW 4TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1328
Practice Address - Country:US
Practice Address - Phone:541-923-7494
Practice Address - Fax:541-504-9153
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR11215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227946Medicaid
OR227946Medicaid