Provider Demographics
NPI:1497226716
Name:JERDE, KAYLA (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:JERDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:24076 SE STARK ST STE 230
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3385
Practice Address - Country:US
Practice Address - Phone:503-488-2600
Practice Address - Fax:503-465-5468
Is Sole Proprietor?:No
Enumeration Date:2018-12-14
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA191582363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2115765Medicaid
OR500758641Medicaid