Provider Demographics
NPI:1063793479
Name:SASADEUSZ, JODI (PT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:SASADEUSZ
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 1:1501 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-2148
Mailing Address - Country:US
Mailing Address - Phone:503-387-5358
Mailing Address - Fax:
Practice Address - Street 1:12045 SE STANLEY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-2938
Practice Address - Country:US
Practice Address - Phone:503-659-2323
Practice Address - Fax:503-659-2766
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3358225100000X
CA27825225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist