Provider Demographics
NPI:1912367681
Name:MADRID, JUSSARA MARISA (RD, LDN)
Entity Type:Individual
Prefix:MISS
First Name:JUSSARA
Middle Name:MARISA
Last Name:MADRID
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 STANTON L YOUNG BLVD STE 430A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5022
Mailing Address - Country:US
Mailing Address - Phone:405-271-8001
Mailing Address - Fax:405-271-5439
Practice Address - Street 1:711 STANTON L YOUNG BLVD STE 430A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5022
Practice Address - Country:US
Practice Address - Phone:405-271-8001
Practice Address - Fax:405-271-5439
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD2121133V00000X
FLND6564133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered