Provider Demographics
NPI:1104651421
Name:BELKNAP, JESSICA L (MS, RD, LD, CLC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:BELKNAP
Suffix:
Gender:F
Credentials:MS, RD, LD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2933
Mailing Address - Country:US
Mailing Address - Phone:503-215-5160
Mailing Address - Fax:
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10240812133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered