Provider Demographics
NPI:1750528766
Name:JENSEN, HEIDI LYN (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYN
Last Name:JENSEN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:LYN
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:PO BOX 928
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78294-0928
Mailing Address - Country:US
Mailing Address - Phone:201-651-0303
Mailing Address - Fax:210-651-0302
Practice Address - Street 1:8811 VILLAGE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5415
Practice Address - Country:US
Practice Address - Phone:201-651-0303
Practice Address - Fax:210-651-0302
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80952133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered