Healthcare Provider Details

I. General information

NPI: 1215406269
Provider Name (Legal Business Name): PATRICIA MIRANDA JARDACK RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2018
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE 37-075 CHS
LOS ANGELES CA
90095-1697
US

IV. Provider business mailing address

1930 OCEAN AVE APT 114
SANTA MONICA CA
90405-1040
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-5768
  • Fax: 310-267-1054
Mailing address:
  • Phone: 310-382-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number872564
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number872564
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: