Provider Demographics
NPI:1467527051
Name:CARLSON, JEAN L (RD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:L
Last Name:CARLSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:L
Other - Last Name:POFFENROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 NE MOTHER JOSEPH PL
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-3200
Mailing Address - Country:US
Mailing Address - Phone:360-514-3409
Mailing Address - Fax:360-514-3590
Practice Address - Street 1:400 NE MOTHER JOSEPH PL
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3200
Practice Address - Country:US
Practice Address - Phone:360-514-3049
Practice Address - Fax:360-514-3590
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI0001455133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered