Provider Demographics
NPI:1134852288
Name:KORENKE, KAJA MADISON (IS)
Entity type:Individual
Prefix:MISS
First Name:KAJA
Middle Name:MADISON
Last Name:KORENKE
Suffix:
Gender:F
Credentials:IS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-4925
Mailing Address - Country:US
Mailing Address - Phone:208-918-9991
Mailing Address - Fax:
Practice Address - Street 1:420 CARDINAL DR
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-4925
Practice Address - Country:US
Practice Address - Phone:208-918-9991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDGC233125AOtherDRIVERS LICENSE NUMBER