Provider Demographics
NPI:1619073178
Name:KHAN, JOETTA M
Entity Type:Individual
Prefix:
First Name:JOETTA
Middle Name:M
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOETTA
Other - Middle Name:M
Other - Last Name:RUEBUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-539-9582
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-539-9582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07527133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered