Provider Demographics
NPI:1710864657
Name:RUSSUM, JACQUELYN CAROLE (RDN)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:CAROLE
Last Name:RUSSUM
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:CAROLE
Other - Last Name:RUSSUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDN
Mailing Address - Street 1:330 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3716
Mailing Address - Country:US
Mailing Address - Phone:510-710-3431
Mailing Address - Fax:
Practice Address - Street 1:3600 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2427
Practice Address - Country:US
Practice Address - Phone:510-383-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA600544133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered