Provider Demographics
NPI:1538312657
Name:FISHER, JENNIFER J (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:FISHER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:J
Other - Last Name:JARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:200 WEST ARBOR DRIVE
Mailing Address - Street 2:MC # 8220
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-8220
Mailing Address - Country:US
Mailing Address - Phone:619-543-5438
Mailing Address - Fax:619-543-7785
Practice Address - Street 1:200 WEST ARBOR DRIVE
Practice Address - Street 2:MC # 8220
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8220
Practice Address - Country:US
Practice Address - Phone:619-543-5438
Practice Address - Fax:619-543-7785
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRD 962434133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABD566ZMedicare PIN