Provider Demographics
NPI:1164832713
Name:NICKELL, JENNIFER (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:NICKELL
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD, CNSC
Mailing Address - Street 1:4948 SW MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2216
Mailing Address - Country:US
Mailing Address - Phone:503-744-2061
Mailing Address - Fax:
Practice Address - Street 1:4948 SW MEADOW AVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2216
Practice Address - Country:US
Practice Address - Phone:503-744-2061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10159758133V00000X
966403133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
966403OtherCOMMISSION ON DIETETIC REGISTRATION