Healthcare Provider Details

I. General information

NPI: 1053692822
Provider Name (Legal Business Name): JODIE LYNN PORGES RR, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 CRANE ST
MENLO PARK CA
94025
US

IV. Provider business mailing address

PO BOX 742244
LOS ANGELES CA
90074-2244
US

V. Phone/Fax

Practice location:
  • Phone: 650-498-6500
  • Fax:
Mailing address:
  • Phone: 650-498-6500
  • Fax: 510-974-8322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.6128
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberRD940744
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: