Provider Demographics
NPI:1215595632
Name:JIANG, MAYBLE L (MS, RD)
Entity Type:Individual
Prefix:
First Name:MAYBLE
Middle Name:L
Last Name:JIANG
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 S AMPHLETT BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2514
Mailing Address - Country:US
Mailing Address - Phone:650-319-8654
Mailing Address - Fax:
Practice Address - Street 1:1650 S AMPHLETT BLVD STE 115
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2514
Practice Address - Country:US
Practice Address - Phone:650-319-8654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86100513133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered