Provider Demographics
NPI:1033406871
Name:JERNSTEDT, KAITLIN EMILY
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:EMILY
Last Name:JERNSTEDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2081 NW EVERETT ST
Mailing Address - Street 2:APT. 506
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1045
Mailing Address - Country:US
Mailing Address - Phone:503-816-3239
Mailing Address - Fax:
Practice Address - Street 1:19250 SW 65TH AVE STE 125
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7745
Practice Address - Country:US
Practice Address - Phone:503-692-1670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR013503235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist