Healthcare Provider Details

I. General information

NPI: 1700280518
Provider Name (Legal Business Name): JACOB DOWLING RD, LD, CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACOB K DOWLING RD, LD, CDE

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

1850 SPRING RIDGE DR
SUSANVILLE CA
96130-6100
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-6632
  • Fax:
Mailing address:
  • Phone: 530-251-1420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86031343
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberLD-1258
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: