Healthcare Provider Details

I. General information

NPI: 1831080555
Provider Name (Legal Business Name): JENELLE YALDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENELLE DETTEN

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15259 SE 82ND DR STE 101
CLACKAMAS OR
97015-6609
US

IV. Provider business mailing address

8414 NE 56TH ST
VANCOUVER WA
98662-6283
US

V. Phone/Fax

Practice location:
  • Phone: 619-633-5491
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberAT4783
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: