Provider Demographics
NPI:1629780192
Name:O'NEILL, JENNIFER CECILIA (RDN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CECILIA
Last Name:O'NEILL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 VIA PACIFICA APT D203
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-4417
Mailing Address - Country:US
Mailing Address - Phone:909-645-3840
Mailing Address - Fax:
Practice Address - Street 1:1350 RECHE CANYON RD
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-9528
Practice Address - Country:US
Practice Address - Phone:909-645-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86172220133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86172220OtherCOMMISSION ON DIETETIC REGISTRATION