Provider Demographics
NPI:1831080555
Name:YALDO, JENELLE
Entity type:Individual
Prefix:
First Name:JENELLE
Middle Name:
Last Name:YALDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:
Other - Last Name:DETTEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8414 NE 56TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15259 SE 82ND DR STE 101
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6609
Practice Address - Country:US
Practice Address - Phone:619-633-5491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-11
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT4783152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics