Provider Demographics
NPI:1104526441
Name:TOOSON, JAEANA ANTONIA (RDN, LD)
Entity type:Individual
Prefix:MRS
First Name:JAEANA
Middle Name:ANTONIA
Last Name:TOOSON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:MISS
Other - First Name:JAEANA
Other - Middle Name:ANTONIA
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1002 LEXINGTON RD STE 25B
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-1480
Mailing Address - Country:US
Mailing Address - Phone:502-735-4579
Mailing Address - Fax:502-570-3719
Practice Address - Street 1:1002 LEXINGTON RD STE 25B
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-1480
Practice Address - Country:US
Practice Address - Phone:502-735-4579
Practice Address - Fax:502-570-3719
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY267659133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty