Provider Demographics
NPI:1760482418
Name:CARPENTER, KERRY JOY (PT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:JOY
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6140
Mailing Address - Country:US
Mailing Address - Phone:541-245-4444
Mailing Address - Fax:541-779-0217
Practice Address - Street 1:977 ROYAL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6140
Practice Address - Country:US
Practice Address - Phone:541-245-4444
Practice Address - Fax:541-779-0217
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1644225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR103682Medicare ID - Type Unspecified