Provider Demographics
NPI:1922694090
Name:PEDERSEN, JACQUELINE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12235 VANCE JACKSON RD APT 932
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-5965
Mailing Address - Country:US
Mailing Address - Phone:319-899-7746
Mailing Address - Fax:
Practice Address - Street 1:12235 VANCE JACKSON RD APT 932
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-5965
Practice Address - Country:US
Practice Address - Phone:319-899-7746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85216133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered