Healthcare Provider Details

I. General information

NPI: 1750944781
Provider Name (Legal Business Name): JENNIFER ANN DEBERDT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

IV. Provider business mailing address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

V. Phone/Fax

Practice location:
  • Phone: 925-370-5000
  • Fax:
Mailing address:
  • Phone: 925-370-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1053751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: