Provider Demographics
NPI:1972674083
Name:JACK, ALEXANDRA M (RD)
Entity Type:Individual
Prefix:MRS
First Name:ALEXANDRA
Middle Name:M
Last Name:JACK
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 1:8716 E MILL PLAIN BLVD
Mailing Address - Street 2:SPECIALTY CLINICS BUILDING
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2531
Mailing Address - Country:US
Mailing Address - Phone:360-514-7932
Mailing Address - Fax:
Practice Address - Street 1:8716 E MILL PLAIN BLVD
Practice Address - Street 2:SPECIALTY CLINICS BUILDING
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2531
Practice Address - Country:US
Practice Address - Phone:360-514-7932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-11
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR560133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR8404915Medicaid