Provider Demographics
NPI:1164593638
Name:PEABODY, JUDY E (ND)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:E
Last Name:PEABODY
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4085 SW 109TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3000
Mailing Address - Country:US
Mailing Address - Phone:503-643-1024
Mailing Address - Fax:
Practice Address - Street 1:4085 SW 109TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3000
Practice Address - Country:US
Practice Address - Phone:503-643-1024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR704175F00000X, 175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered175F00000XOther Service ProvidersNaturopath
Not Answered175L00000XOther Service ProvidersHomeopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022553OtherOREGON MEDICAL ASSISTANCE
ORBP6912996OtherDEA