Basic Information
| Provider Information | |||||||||
| NPI: | 1487911145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YACOUB | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.P.H., R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10000 LAKEWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902404020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628623684 | ||||||||
| FaxNumber: | 5628627145 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 LAKEWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902404020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628623684 | ||||||||
| FaxNumber: | 5628627145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1022607 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1022607 | 01 | CA | REGISTERED DIETITIAN | OTHER |