Provider Demographics
NPI:1659737013
Name:JAYABALAN, MUTHUMEENA (MS,RDN,LD)
Entity Type:Individual
Prefix:
First Name:MUTHUMEENA
Middle Name:
Last Name:JAYABALAN
Suffix:
Gender:F
Credentials:MS,RDN,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 CAVEAT CT
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4434
Mailing Address - Country:US
Mailing Address - Phone:248-921-6582
Mailing Address - Fax:
Practice Address - Street 1:5880 CAVEAT CT
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4434
Practice Address - Country:US
Practice Address - Phone:248-921-6582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004133133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered