Provider Demographics
NPI:1700961851
Name:JEROME, DENISE COLETTE (PT)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:COLETTE
Last Name:JEROME
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 1:1001 SW EMKAY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3663
Mailing Address - Country:US
Mailing Address - Phone:541-385-3344
Mailing Address - Fax:541-312-5256
Practice Address - Street 1:1001 SW EMKAY DR STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3663
Practice Address - Country:US
Practice Address - Phone:541-385-3344
Practice Address - Fax:541-312-5256
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63611225100000X
AK1607225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT1607Medicaid
AK1972643138OtherNPI # EQUINOX,INC
AK1972643138OtherNPI # EQUINOX,INC