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General NPI Number Information
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NPI Number | 1326242520
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Entity Type | Individual
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Provider Name | JENNA TAYLOR BRADDOCK RD, LDN
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Gender | Female
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Dates
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Enumeration Date | 06/12/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3100 UNIVERSITY BLVD S SUITE 220
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City | JACKSONVILLE
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State | FL
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Zip | 32216-2758
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Country | US
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Telephone | 904-724-2043
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Fax | 904-724-2013
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Provider Business Mailing Address
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Address Line | 947 SCRUB JAY DR
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32092-1759
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Country | US
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Telephone | 904-810-0368
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | ND 4851
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License Number State | FL
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