Provider Demographics
NPI:1033528443
Name:LUDTKE, JENNIFER (ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LUDTKE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:JENNI
Other - Middle Name:
Other - Last Name:LUDTKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:1739 NE 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2009
Mailing Address - Country:US
Mailing Address - Phone:559-707-1953
Mailing Address - Fax:
Practice Address - Street 1:5210 N KERBY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2699
Practice Address - Country:US
Practice Address - Phone:559-707-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-102064312255A2300X
CA20000185172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORAT-AT-10206431OtherSTATE LICENSURE