Provider Demographics
NPI:1154967461
Name:ELLIGOTT, JESSICA IRENE (CDCES, MS, RDN, CDN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:IRENE
Last Name:ELLIGOTT
Suffix:
Gender:F
Credentials:CDCES, MS, RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19000 SE 23RD ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9794
Mailing Address - Country:US
Mailing Address - Phone:360-601-2580
Mailing Address - Fax:
Practice Address - Street 1:2101 NE 139TH ST STE 460
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2325
Practice Address - Country:US
Practice Address - Phone:360-360-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60596850163WD0400X, 133V00000X
ORDI60596850163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered