Provider Demographics
NPI:1891761086
Name:JACOBSON, MELISSA DAWN (RD, CDE)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:DAWN
Last Name:JACOBSON
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 1:8036 SE 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-8950
Mailing Address - Country:US
Mailing Address - Phone:503-774-7940
Mailing Address - Fax:
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE LL10
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-413-7227
Practice Address - Fax:503-413-6888
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR602133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR114176Medicare PIN
ORP70233Medicare UPIN