Provider Demographics
NPI:1164121075
Name:SKOUBO, JORDAN (RD, MPH, CPH)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SKOUBO
Suffix:
Gender:M
Credentials:RD, MPH, CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 OAKRIDGE RD APT 10
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1750 MCGILCHRIST ST SE STE 130
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1691
Practice Address - Country:US
Practice Address - Phone:971-304-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered