Provider Demographics
NPI:1689292815
Name:SUTHERLAND, JODI ANN
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:ANN
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54910, PINE CREST AVENUE
Mailing Address - Street 2:
Mailing Address - City:IDYLLWILD
Mailing Address - State:CA
Mailing Address - Zip Code:92549-9254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54910, PINE CREST AVENUE
Practice Address - Street 2:
Practice Address - City:IDYLLWILD
Practice Address - State:CA
Practice Address - Zip Code:92549-9254
Practice Address - Country:US
Practice Address - Phone:951-659-9912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty