Provider Demographics
NPI:1275952509
Name:CROSDALE, JENNIFER (MS, RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CROSDALE
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 1:715 N MARGUERITA AVE
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1248
Mailing Address - Country:US
Mailing Address - Phone:626-626-1346
Mailing Address - Fax:
Practice Address - Street 1:715 N MARGUERITA AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-1248
Practice Address - Country:US
Practice Address - Phone:626-626-1346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA925850133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered