Provider Demographics
NPI:1619751237
Name:VARGAS, JENNIFER L (RD)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:VARGAS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 FLATT LN
Mailing Address - Street 2:
Mailing Address - City:GROTTOES
Mailing Address - State:VA
Mailing Address - Zip Code:24441-2420
Mailing Address - Country:US
Mailing Address - Phone:401-480-6963
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1055
Practice Address - Street 2:
Practice Address - City:GROTTOES
Practice Address - State:VA
Practice Address - Zip Code:24441-1055
Practice Address - Country:US
Practice Address - Phone:401-480-6963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006621133V00000X
FLND10169133V00000X
MDDX3568133V00000X
DCDI200001391133V00000X
IL164009400133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered