Provider Demographics
NPI:1770606287
Name:RAINES, JENNIFER KAY (RD, CDE)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAY
Last Name:RAINES
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 BRIDGESTONE DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-2192
Mailing Address - Country:US
Mailing Address - Phone:817-368-4676
Mailing Address - Fax:
Practice Address - Street 1:1911 BRIDGESTONE DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:TX
Practice Address - Zip Code:76210-2192
Practice Address - Country:US
Practice Address - Phone:817-368-4676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81756133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered