Provider Demographics
NPI:1891366886
Name:CONTRERAS, JONATHAN (RD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CONTRERAS
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 TINA AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-1143
Mailing Address - Country:US
Mailing Address - Phone:781-534-0108
Mailing Address - Fax:
Practice Address - Street 1:72 TINA AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-1143
Practice Address - Country:US
Practice Address - Phone:781-534-0108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4979-NU-NU133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist