Provider Demographics
NPI:1710588686
Name:SHANE, JONATHAN S (FNTP)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:S
Last Name:SHANE
Suffix:
Gender:M
Credentials:FNTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3038 VILLAGE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-6950
Mailing Address - Country:US
Mailing Address - Phone:832-285-6739
Mailing Address - Fax:
Practice Address - Street 1:3038 VILLAGE CREEK DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-6950
Practice Address - Country:US
Practice Address - Phone:832-285-6739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5275133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education