Provider Demographics
NPI:1972012409
Name:PORTLAND PEDIATRIC NUTRITION
Entity Type:Organization
Organization Name:PORTLAND PEDIATRIC NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHARINE
Authorized Official - Middle Name:BURTON
Authorized Official - Last Name:JEFFCOAT
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LD, CLT
Authorized Official - Phone:503-997-8897
Mailing Address - Street 1:3230 SW GALE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-1450
Mailing Address - Country:US
Mailing Address - Phone:503-997-8897
Mailing Address - Fax:
Practice Address - Street 1:1730 SW SKYLINE BLVD STE 226
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2549
Practice Address - Country:US
Practice Address - Phone:971-319-1288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-000479133V00000X, 133VN1004X
WADI60717826133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Single Specialty