Provider Demographics
NPI:1396047742
Name:BECKER-CORBIN, JENNA MARIE (RD)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:MARIE
Last Name:BECKER-CORBIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 CARTILLA AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-1756
Mailing Address - Country:US
Mailing Address - Phone:909-731-9936
Mailing Address - Fax:
Practice Address - Street 1:4805 BAY HERON PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33616-2948
Practice Address - Country:US
Practice Address - Phone:909-731-9936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01004023133V00000X
FLND1405133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered