Provider Demographics
NPI:1972680726
Name:VAN DYKE, JEANA BARBARA (RD, LD, CDE)
Entity Type:Individual
Prefix:MS
First Name:JEANA
Middle Name:BARBARA
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 6TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1916
Mailing Address - Country:US
Mailing Address - Phone:541-812-4000
Mailing Address - Fax:541-812-4145
Practice Address - Street 1:631 ELM ST SW
Practice Address - Street 2:SUITE 202
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1952
Practice Address - Country:US
Practice Address - Phone:541-812-4844
Practice Address - Fax:541-812-4849
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000503133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500639570Medicaid