Provider Demographics
NPI:1902897879
Name:DE RUIJTER, JODY ANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:ANNE
Last Name:DE RUIJTER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2493 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4543
Mailing Address - Country:US
Mailing Address - Phone:503-588-1010
Mailing Address - Fax:503-588-9424
Practice Address - Street 1:2493 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4543
Practice Address - Country:US
Practice Address - Phone:503-588-1010
Practice Address - Fax:503-588-9424
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1612103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical