Provider Demographics
NPI:1891202396
Name:MICHAEL, JEROD PAUL (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JEROD
Middle Name:PAUL
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19198 CHOCTAW RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-8961
Mailing Address - Country:US
Mailing Address - Phone:541-728-3349
Mailing Address - Fax:
Practice Address - Street 1:19198 CHOCTAW RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-8961
Practice Address - Country:US
Practice Address - Phone:541-728-3349
Practice Address - Fax:888-782-4224
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15153235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist