Provider Demographics
NPI:1912318627
Name:KADUK-GALLAGHER, JEAN (RD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:KADUK-GALLAGHER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78952 SPIRITO CT
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-4016
Mailing Address - Country:US
Mailing Address - Phone:760-464-4821
Mailing Address - Fax:
Practice Address - Street 1:78952 SPIRITO CT
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-4016
Practice Address - Country:US
Practice Address - Phone:760-464-4821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
467382133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered