Provider Demographics
NPI:1679891501
Name:MOON, JODI RAE (RD, CDE)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:RAE
Last Name:MOON
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 15TH ST
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1448
Mailing Address - Country:US
Mailing Address - Phone:503-650-6822
Mailing Address - Fax:503-650-6876
Practice Address - Street 1:519 15TH ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1448
Practice Address - Country:US
Practice Address - Phone:503-650-6822
Practice Address - Fax:503-650-6876
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR674133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered