Provider Demographics
NPI:1700120193
Name:BERGHOFF, JESSICA BETH (RD CD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BETH
Last Name:BERGHOFF
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-1034
Mailing Address - Country:US
Mailing Address - Phone:509-939-2241
Mailing Address - Fax:
Practice Address - Street 1:10102 E 17TH LN
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-3427
Practice Address - Country:US
Practice Address - Phone:509-939-2241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1018452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered