Basic Information
| Provider Information | |||||||||
| NPI: | 1265053425 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYBAKKEN | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | ELISE | ||||||||
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| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5815 RED LEAF DR S APT 217 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973063025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184648223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 890 OAK ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973013905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035615200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2020 | ||||||||
| LastUpdateDate: | 04/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD-D-10204599 | OR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.