Basic Information
| Provider Information | |||||||||
| NPI: | 1700280518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOWLING | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD, LD, CDE | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DOWLING | ||||||||
| OtherFirstName: | JACOB | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherCredential: | RD, LD, CDE | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1850 SPRING RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961306100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302511420 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052726632 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2014 | ||||||||
| LastUpdateDate: | 01/13/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86031343 | CA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1004X | LD-1258 | NM | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
No ID Information.