Provider Demographics
NPI:1053457663
Name:HAVENS, JO R (DT)
Entity Type:Individual
Prefix:MS
First Name:JO
Middle Name:R
Last Name:HAVENS
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1701 N COLLINS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3564
Mailing Address - Country:US
Mailing Address - Phone:469-385-4900
Mailing Address - Fax:469-385-4265
Practice Address - Street 1:1701 N COLLINS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3564
Practice Address - Country:US
Practice Address - Phone:469-385-4900
Practice Address - Fax:469-385-4265
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXDT04929133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered