Provider Demographics
NPI:1326242520
Name:BRADDOCK, JENNA TAYLOR (RD, LDN)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:TAYLOR
Last Name:BRADDOCK
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:947 SCRUB JAY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1759
Mailing Address - Country:US
Mailing Address - Phone:904-810-0368
Mailing Address - Fax:
Practice Address - Street 1:3100 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2758
Practice Address - Country:US
Practice Address - Phone:904-724-2043
Practice Address - Fax:904-724-2013
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 4851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered