Provider Demographics
NPI:1396167433
Name:JONES, DYLAN A (PA-S,RDN, CDCES, CES)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:A
Last Name:JONES
Suffix:
Gender:M
Credentials:PA-S,RDN, CDCES, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 S MOODY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2730 S MOODY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5042
Practice Address - Country:US
Practice Address - Phone:360-624-4942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60285507133V00000X
390200000X
ORLD-D-10170730133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2106736Medicaid
OR500703814Medicaid