Provider Demographics
NPI:1740336528
Name:HERNANDEZ, JENNIFER L (MS, RD)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:BLEDSOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:8441 W CROWN KING RD
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-3619
Mailing Address - Country:US
Mailing Address - Phone:314-972-4615
Mailing Address - Fax:480-833-9426
Practice Address - Street 1:40 W BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3400
Practice Address - Country:US
Practice Address - Phone:314-972-4615
Practice Address - Fax:480-833-9426
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ895245133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered