Provider Demographics
NPI:1275753527
Name:JERGENSON, BRINA ROCHELLE (RD)
Entity Type:Individual
Prefix:
First Name:BRINA
Middle Name:ROCHELLE
Last Name:JERGENSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 N DOBSON RD
Mailing Address - Street 2:BUILDING C; SUITE 113
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-9601
Mailing Address - Country:US
Mailing Address - Phone:602-538-6852
Mailing Address - Fax:480-491-5719
Practice Address - Street 1:3200 N DOBSON RD
Practice Address - Street 2:BUILDING C; SUITE 113
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-9601
Practice Address - Country:US
Practice Address - Phone:602-538-6852
Practice Address - Fax:480-491-5719
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
844424133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered