Provider Demographics
NPI:1447785977
Name:EVANS, JODY (CN)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 EASTLAKE RD
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98844-9558
Mailing Address - Country:US
Mailing Address - Phone:360-986-9799
Mailing Address - Fax:
Practice Address - Street 1:1321 MAIN ST UNIT A
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:WA
Practice Address - Zip Code:98844-9384
Practice Address - Country:US
Practice Address - Phone:360-986-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU 60731669133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist