Provider Demographics
NPI:1437456845
Name:JEDLICKA, MICHAEL (SLP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:JEDLICKA
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7244
Mailing Address - Country:US
Mailing Address - Phone:503-666-1333
Mailing Address - Fax:503-666-2444
Practice Address - Street 1:532 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7244
Practice Address - Country:US
Practice Address - Phone:503-666-1333
Practice Address - Fax:503-666-2444
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12708235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist