Provider Demographics
NPI:1053692822
Name:PORGES, JODIE LYNN (RR, CDE)
Entity type:Individual
Prefix:MS
First Name:JODIE
Middle Name:LYNN
Last Name:PORGES
Suffix:
Gender:F
Credentials:RR, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742244
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2244
Mailing Address - Country:US
Mailing Address - Phone:650-498-6500
Mailing Address - Fax:510-974-8322
Practice Address - Street 1:1300 CRANE ST
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025
Practice Address - Country:US
Practice Address - Phone:650-498-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.6128133V00000X
CARD940744133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered