Provider Demographics
NPI:1124792957
Name:LANE, JENNIFER (MS, RDN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S MCDOWELL BLVD # 1063
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-3505
Mailing Address - Country:US
Mailing Address - Phone:707-338-2474
Mailing Address - Fax:707-221-1688
Practice Address - Street 1:207 S MCDOWELL BLVD # 1063
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-3505
Practice Address - Country:US
Practice Address - Phone:707-338-2474
Practice Address - Fax:707-221-1688
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA984565133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered