Provider Demographics
NPI:1003381286
Name:IBARRA, JOSEPH JAMIE (MCN, RDN, LD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:JAMIE
Last Name:IBARRA
Suffix:
Gender:M
Credentials:MCN, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2528 MARINA DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6851
Mailing Address - Country:US
Mailing Address - Phone:909-636-1340
Mailing Address - Fax:
Practice Address - Street 1:2528 MARINA DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75054-6851
Practice Address - Country:US
Practice Address - Phone:909-636-1340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86146437133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered