Provider Demographics
NPI:1922877992
Name:CARDONA, JENNELY
Entity Type:Individual
Prefix:
First Name:JENNELY
Middle Name:
Last Name:CARDONA
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 1:15710 KOI GARDENS LN
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77302-1421
Mailing Address - Country:US
Mailing Address - Phone:787-469-8857
Mailing Address - Fax:
Practice Address - Street 1:15710 KOI GARDENS LN
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77302-1421
Practice Address - Country:US
Practice Address - Phone:787-469-8857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1820133V00000X
TX88329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered