Provider Demographics
NPI:1033759865
Name:MCNINCH, JOLAN SU (RD,LD)
Entity Type:Individual
Prefix:
First Name:JOLAN
Middle Name:SU
Last Name:MCNINCH
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5224
Mailing Address - Street 2:
Mailing Address - City:MANGILAO
Mailing Address - State:GU
Mailing Address - Zip Code:96923-5224
Mailing Address - Country:US
Mailing Address - Phone:671-487-7206
Mailing Address - Fax:
Practice Address - Street 1:3108 GREENPARK CONDO, WASHINGTON DRIVE
Practice Address - Street 2:
Practice Address - City:MANGILAO
Practice Address - State:GU
Practice Address - Zip Code:96923-9692
Practice Address - Country:US
Practice Address - Phone:671-487-7206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU05133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered