Provider Demographics
NPI:1235523119
Name:GLASS, JENNIFER NANI (RDN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NANI
Last Name:GLASS
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 1:175 N JACKSON AVE
Mailing Address - Street 2:SUITE #209
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1909
Mailing Address - Country:US
Mailing Address - Phone:510-320-3438
Mailing Address - Fax:
Practice Address - Street 1:175 N JACKSON AVE
Practice Address - Street 2:SUITE #209
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1909
Practice Address - Country:US
Practice Address - Phone:510-320-3438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1079703133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered