Provider Demographics
NPI:1780950824
Name:DAVIS, JEANNENE ANN (RD,LD)
Entity type:Individual
Prefix:MS
First Name:JEANNENE
Middle Name:ANN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31021 WALNUT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WALLER
Mailing Address - State:TX
Mailing Address - Zip Code:77484-5986
Mailing Address - Country:US
Mailing Address - Phone:936-372-3784
Mailing Address - Fax:
Practice Address - Street 1:31021 WALNUT RIDGE DR
Practice Address - Street 2:
Practice Address - City:WALLER
Practice Address - State:TX
Practice Address - Zip Code:77484-5986
Practice Address - Country:US
Practice Address - Phone:936-372-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDTO6453133N00000X, 133NN1002X, 133V00000X, 133VN1005X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic