Provider Demographics
NPI:1407122112
Name:HAGENDORF, JENNIFER L (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:HAGENDORF
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:GUERRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:7703 FLOYD CURL DR
Mailing Address - Street 2:MC7977
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:210-450-9000
Mailing Address - Fax:
Practice Address - Street 1:8300 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3931
Practice Address - Country:US
Practice Address - Phone:210-450-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80988133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB151869Medicare PIN