Provider Demographics
NPI:1508249384
Name:FRAGOSO, JESSIE (RD)
Entity Type:Individual
Prefix:MR
First Name:JESSIE
Middle Name:
Last Name:FRAGOSO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11812 JULIUS AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-4612
Mailing Address - Country:US
Mailing Address - Phone:562-659-4081
Mailing Address - Fax:
Practice Address - Street 1:11812 JULIUS AVE
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4612
Practice Address - Country:US
Practice Address - Phone:562-659-4081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86045829133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered