Provider Demographics
NPI:1871585802
Name:YOON, JERRY J (DPM)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:J
Last Name:YOON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 KRUSE WAY PL STE 220
Mailing Address - Street 2:BLDG 2
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5545
Mailing Address - Country:US
Mailing Address - Phone:503-636-9656
Mailing Address - Fax:503-636-9657
Practice Address - Street 1:4000 KRUSE WAY PL STE 220
Practice Address - Street 2:BLDG 2
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5545
Practice Address - Country:US
Practice Address - Phone:503-636-9656
Practice Address - Fax:503-636-9657
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00338213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286958Medicaid
U81436Medicare UPIN
OR111904Medicare ID - Type Unspecified
OR5503160001Medicare NSC
OR286958Medicaid