Basic Information
Provider Information | |||||||||
NPI: | 1336458918 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SANTANA | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DIETITAN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | M8 CALLE LIRIOS | ||||||||
Address2: | JARDINES DE BORINQUEN | ||||||||
City: | CAROLINA | ||||||||
State: | PR | ||||||||
PostalCode: | 009854227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7874394692 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1715 AVE PONCE DE LEON | ||||||||
Address2: | NUTRITION DEPT. | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 009091958 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7877582000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2010 | ||||||||
LastUpdateDate: | 09/30/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 1468 | PR | Y |   | Dietary & Nutritional Service Providers | Nutritionist |   |
ID Information
ID | Type | State | Issuer | Description | 1468 | 01 | PR | DIETITIAN'S LICENSE | OTHER |