Provider Demographics
NPI:1225048879
Name:WOLK, JANICE CAROL (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:CAROL
Last Name:WOLK
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 574
Mailing Address - Street 2:
Mailing Address - City:GARIBALDI
Mailing Address - State:OR
Mailing Address - Zip Code:97118-0574
Mailing Address - Country:US
Mailing Address - Phone:503-322-2719
Mailing Address - Fax:
Practice Address - Street 1:1000 3RD ST
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3430
Practice Address - Country:US
Practice Address - Phone:503-815-2287
Practice Address - Fax:503-815-2254
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR308133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP62813Medicare UPIN