Healthcare Provider Details

I. General information

NPI: 1306298211
Provider Name (Legal Business Name): JACKIE ROVELL RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2094 ERINS PL
ESCONDIDO CA
92027-1171
US

IV. Provider business mailing address

2094 ERINS PL
ESCONDIDO CA
92027-1171
US

V. Phone/Fax

Practice location:
  • Phone: 760-715-6953
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number717054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: