Provider Demographics
NPI:1265830343
Name:FOSAAEN, JEROME (RD, LD/N)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:FOSAAEN
Suffix:
Gender:M
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 SANTA MARIE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5478
Mailing Address - Country:US
Mailing Address - Phone:904-417-7344
Mailing Address - Fax:
Practice Address - Street 1:1605 SANTA MARIE CT
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-5478
Practice Address - Country:US
Practice Address - Phone:904-417-7344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4527133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered