Provider Demographics
NPI:1447864590
Name:JUDIE, JACQUELINE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JUDIE
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 TREMONT ST
Mailing Address - Street 2:# 8051
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-5490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 9TH AVE N APT 612
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77590-6559
Practice Address - Country:US
Practice Address - Phone:817-681-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-05
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered