Provider Demographics
NPI:1073399598
Name:JACONETTA, LAURA M (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:M
Last Name:JACONETTA
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3681 DURKSLY DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1338
Mailing Address - Country:US
Mailing Address - Phone:615-495-5358
Mailing Address - Fax:
Practice Address - Street 1:1000 36TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4862
Practice Address - Country:US
Practice Address - Phone:772-567-4311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND11487133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLND11487OtherSTATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE