Healthcare Provider Details

I. General information

NPI: 1407168214
Provider Name (Legal Business Name): JENNIFER DEFRAIN MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER DEFRAIN MS, RD

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 QUAIL ST SUITE #110
NEWPORT BEACH CA
92660-2701
US

IV. Provider business mailing address

1100 QUAIL ST SUITE #110
NEWPORT BEACH CA
92660-2701
US

V. Phone/Fax

Practice location:
  • Phone: 949-874-3438
  • Fax: 866-372-1190
Mailing address:
  • Phone: 949-874-3438
  • Fax: 866-372-1190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number811508
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number811508
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number811508
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: