Provider Demographics
NPI:1588068522
Name:HALL, JESSE RAY (MS, RDN, CD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:RAY
Last Name:HALL
Suffix:
Gender:M
Credentials:MS, RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5940 ULALI DR NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-1500
Mailing Address - Country:US
Mailing Address - Phone:503-304-5738
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:5940 ULALI DR NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-1500
Practice Address - Country:US
Practice Address - Phone:503-304-5738
Practice Address - Fax:503-304-5725
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60506429133V00000X
OR10179690133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered