MEDICARE: MRS. SUSAN THOMAS JASTROW RD, LD, CDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT04706	TX

General Provider Information

NPI Number	:	1215161104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN THOMAS JASTROW RD, LD, CDE

Provider Business Mailing Address
First Line	:	1242 PT RANCH ROAD
Second Line	:
City	:	ROUND MOUNTAIN
State	:	TX
Zip	:	78663-5990
Country	:	US
Telephone Number	:	512-466-4407
Fax Number	:	830-825-2400

Provider Business Practice Location Address
First Line	:	1242 PT RANCH RD
Second Line	:
City	:	ROUND MOUNTAIN
State	:	TX
Zip	:	78663-5990
Country	:	US
Telephone Number	:	512-466-4407
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2009
Last Update Date	:	04/25/2013

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