Provider Demographics
NPI:1629684295
Name:DE LA TORRE, JACQUELINE LUCERO (RDN, CDCES)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LUCERO
Last Name:DE LA TORRE
Suffix:
Gender:F
Credentials:RDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1994 N RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1734
Mailing Address - Country:US
Mailing Address - Phone:626-399-2958
Mailing Address - Fax:
Practice Address - Street 1:1994 N RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-1734
Practice Address - Country:US
Practice Address - Phone:626-399-2958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-19
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86144051133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered