Provider Demographics
NPI:1013404136
Name:WAKAMATSU, JEANNIE (MPH, RD)
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:WAKAMATSU
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10312 ALMAYO AVE.
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064
Mailing Address - Country:US
Mailing Address - Phone:213-740-1728
Mailing Address - Fax:
Practice Address - Street 1:10312 ALMAYO AVE.
Practice Address - Street 2:SUITE 6
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064
Practice Address - Country:US
Practice Address - Phone:213-740-1728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA889669133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered