Healthcare Provider Details

I. General information

NPI: 1164121075
Provider Name (Legal Business Name): JORDAN SKOUBO RD, MPH, CPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 MCGILCHRIST ST SE STE 130
SALEM OR
97302-1691
US

IV. Provider business mailing address

4400 OAKRIDGE RD APT 10
LAKE OSWEGO OR
97035-3390
US

V. Phone/Fax

Practice location:
  • Phone: 971-304-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: