Provider Demographics
NPI:1407242431
Name:VREDENBURG, JONATHAN (RD,LD/N)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:VREDENBURG
Suffix:
Gender:M
Credentials:RD,LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1768 OLEANDER PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-2250
Mailing Address - Country:US
Mailing Address - Phone:904-630-0911
Mailing Address - Fax:904-630-4585
Practice Address - Street 1:1805 FLAG ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-5882
Practice Address - Country:US
Practice Address - Phone:904-630-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND2702133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered