Provider Demographics
NPI:1124015433
Name:KJOS, HEIDI (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:KJOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:3101 SE 192ND AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1442
Practice Address - Country:US
Practice Address - Phone:360-553-7300
Practice Address - Fax:360-553-7450
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153026207Q00000X
WAMD60200769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00946521OtherRR MEDICARE
OR500631081Medicaid
WAP00946521OtherRR MEDICARE