Provider Demographics
NPI:1730430562
Name:KARADIMAS, JAN KYOKO (PSYD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:KYOKO
Last Name:KARADIMAS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:JAN
Other - Middle Name:KYOKO
Other - Last Name:YOMOGIDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10011 SE DIVISION ST STE 203
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1354
Mailing Address - Country:US
Mailing Address - Phone:503-505-3435
Mailing Address - Fax:503-255-2344
Practice Address - Street 1:10011 SE DIVISION ST STE 203
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1354
Practice Address - Country:US
Practice Address - Phone:503-233-5405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2491103TC0700X
HI133V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program