Provider Demographics
NPI:1417025016
Name:CARDER, JACQUELINE S (RD, LD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:S
Last Name:CARDER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13214 LOMA VALLEJO
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233-2418
Mailing Address - Country:US
Mailing Address - Phone:402-429-3543
Mailing Address - Fax:210-579-6489
Practice Address - Street 1:13214 LOMA VALLEJO
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78233-2418
Practice Address - Country:US
Practice Address - Phone:402-429-3543
Practice Address - Fax:210-579-6489
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81640133VN1005X, 133NN1002X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
278140Medicare ID - Type Unspecified