Provider Demographics
NPI:1538427703
Name:JOLLEY, CASSANDRA DAWN (RD)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:DAWN
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-1917
Mailing Address - Country:US
Mailing Address - Phone:971-983-5337
Mailing Address - Fax:
Practice Address - Street 1:1475 MOUNT HOOD AVE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-9066
Practice Address - Country:US
Practice Address - Phone:971-983-5337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-000975133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered