Provider Demographics
NPI:1922643865
Name:FANGONILO, JACQUELINE ALEJANDRA GAYTAN
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ALEJANDRA GAYTAN
Last Name:FANGONILO
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 1:130 ESCANYO DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-4134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:240 SHOTWELL ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-1323
Practice Address - Country:US
Practice Address - Phone:415-552-1013
Practice Address - Fax:415-552-7040
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered