Provider Demographics
NPI:1740652692
Name:DEVORE, JACQUE (RD, MPH, LD)
Entity type:Individual
Prefix:
First Name:JACQUE
Middle Name:
Last Name:DEVORE
Suffix:
Gender:F
Credentials:RD, MPH, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 SE 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-5635
Mailing Address - Country:US
Mailing Address - Phone:503-753-4561
Mailing Address - Fax:
Practice Address - Street 1:6725 SE 19TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5635
Practice Address - Country:US
Practice Address - Phone:503-753-4561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-29
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD D 10151892133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric