Healthcare Provider Details

I. General information

NPI: 1689292815
Provider Name (Legal Business Name): JODI ANN SUTHERLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54910, PINE CREST AVENUE
IDYLLWILD CA
92549-9254
US

IV. Provider business mailing address

54910, PINE CREST AVENUE
IDYLLWILD CA
92549-9254
US

V. Phone/Fax

Practice location:
  • Phone: 951-659-9912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: