Provider Demographics
NPI:1215406269
Name:JARDACK, PATRICIA MIRANDA (RDN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MIRANDA
Last Name:JARDACK
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 OCEAN AVE APT 114
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-1040
Mailing Address - Country:US
Mailing Address - Phone:310-382-7575
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:37-075 CHS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1697
Practice Address - Country:US
Practice Address - Phone:310-825-5768
Practice Address - Fax:310-267-1054
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA872564133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
872564OtherRDN REGISTRATION