Provider Demographics
NPI:1417099391
Name:EKVALL, JEAN ANN (RD, DRPH, CHES, RN)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:ANN
Last Name:EKVALL
Suffix:
Gender:F
Credentials:RD, DRPH, CHES, RN
Other - Prefix:DR
Other - First Name:JEANNE
Other - Middle Name:ANN
Other - Last Name:EKVALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, DRPH, CHES, RN
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:WA
Mailing Address - Zip Code:98812-0337
Mailing Address - Country:US
Mailing Address - Phone:509-689-2525
Mailing Address - Fax:509-689-3247
Practice Address - Street 1:520 W INDIAN AVE
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812
Practice Address - Country:US
Practice Address - Phone:509-689-2525
Practice Address - Fax:509-689-3247
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000848133V00000X
WARN00119314163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8260127Medicaid
WAAB28282Medicare ID - Type Unspecified