Provider Demographics
NPI:1407168214
Name:DEFRAIN, JENNIFER (MS, RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEFRAIN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:DEFRAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:1100 QUAIL ST
Mailing Address - Street 2:SUITE #110
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2701
Mailing Address - Country:US
Mailing Address - Phone:949-874-3438
Mailing Address - Fax:866-372-1190
Practice Address - Street 1:1100 QUAIL ST
Practice Address - Street 2:SUITE #110
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2701
Practice Address - Country:US
Practice Address - Phone:949-874-3438
Practice Address - Fax:866-372-1190
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
811508133NN1002X, 133V00000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic