Healthcare Provider Details

I. General information

NPI: 1154967461
Provider Name (Legal Business Name): JESSICA IRENE ELLIGOTT CDCES, MS, RDN, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 NE 139TH ST STE 460
VANCOUVER WA
98686-2325
US

IV. Provider business mailing address

19000 SE 23RD ST
VANCOUVER WA
98683-9794
US

V. Phone/Fax

Practice location:
  • Phone: 360-360-4872
  • Fax:
Mailing address:
  • Phone: 360-601-2580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberDI60596850
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberDI60596850
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60596850
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: