Provider Demographics
NPI:1033306782
Name:STOUT, JOLENE M (DPT)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:M
Last Name:STOUT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JOLENE
Other - Middle Name:M
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1441 SW CHANDLER AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3208
Mailing Address - Country:US
Mailing Address - Phone:541-797-3052
Mailing Address - Fax:541-797-7672
Practice Address - Street 1:946 SW VETERANS WAY STE 100
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2700
Practice Address - Country:US
Practice Address - Phone:541-527-4386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5784225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270927Medicaid
ORR147032Medicare PIN