Provider Demographics
NPI:1912449919
Name:WYMORE, JONATHAN (RD, LD)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:WYMORE
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:DOUGLAS
Other - Last Name:WYMORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LD
Mailing Address - Street 1:620 ELM ST SW # 2
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1986
Mailing Address - Country:US
Mailing Address - Phone:541-812-4839
Mailing Address - Fax:
Practice Address - Street 1:620 ELM ST SW # 2
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1986
Practice Address - Country:US
Practice Address - Phone:541-812-4839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDD10175002133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86065504OtherCOMMISION ON DIETETIC REGISTRATION
ORLDD10175002OtherOREGON DIETETIC LICENSURE