Healthcare Provider Details

I. General information

NPI: 1972012409
Provider Name (Legal Business Name): PORTLAND PEDIATRIC NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 SW SKYLINE BLVD STE 226
PORTLAND OR
97221-2549
US

IV. Provider business mailing address

3230 SW GALE AVE
PORTLAND OR
97239-1450
US

V. Phone/Fax

Practice location:
  • Phone: 971-319-1288
  • Fax:
Mailing address:
  • Phone: 503-997-8897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60717826
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberLD-D-000479
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-000479
License Number StateOR

VIII. Authorized Official

Name: MRS. KATHARINE BURTON JEFFCOAT
Title or Position: DIETITIAN/OWNER
Credential: RDN, LD, CLT
Phone: 503-997-8897