Provider Demographics
NPI:1639287634
Name:JASSO-GLAVY, CARLA A (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:A
Last Name:JASSO-GLAVY
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5107 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-614-8612
Mailing Address - Fax:210-615-5596
Practice Address - Street 1:5107 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-614-8612
Practice Address - Fax:210-615-5596
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P57523Medicare UPIN
87N506Medicare ID - Type Unspecified