Provider Demographics
NPI:1104083492
Name:HANN, JESSIE ROBERTA (MS,RD,LD,CD,CDCES)
Entity type:Individual
Prefix:MS
First Name:JESSIE
Middle Name:ROBERTA
Last Name:HANN
Suffix:
Gender:F
Credentials:MS,RD,LD,CD,CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NE 102ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3804
Mailing Address - Country:US
Mailing Address - Phone:503-250-4326
Mailing Address - Fax:971-229-6709
Practice Address - Street 1:1700 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3804
Practice Address - Country:US
Practice Address - Phone:503-250-4326
Practice Address - Fax:971-229-6709
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR461133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered