Provider Demographics
NPI:1689867830
Name:GRACE, JANE MARIE (RD)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:MARIE
Last Name:GRACE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18380 WILLAMETTE DR
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-1200
Mailing Address - Country:US
Mailing Address - Phone:503-697-4171
Mailing Address - Fax:503-697-1002
Practice Address - Street 1:18380 WILLAMETTE DR
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-1200
Practice Address - Country:US
Practice Address - Phone:503-697-4171
Practice Address - Fax:503-697-1002
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL328032133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered