Healthcare Provider Details

I. General information

NPI: 1093583916
Provider Name (Legal Business Name): JAYDEN MONTEJANO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15301 WARREN SHINGLE RD
BEALE AFB CA
95903-1905
US

IV. Provider business mailing address

1424 5TH ST
COLUSA CA
95932-3004
US

V. Phone/Fax

Practice location:
  • Phone: 530-634-2941
  • Fax:
Mailing address:
  • Phone: 530-844-0121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: