Provider Demographics
NPI:1124477583
Name:MY NUTRITION STUDIO
Entity type:Organization
Organization Name:MY NUTRITION STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAGENDORF
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN, LD
Authorized Official - Phone:210-320-0979
Mailing Address - Street 1:305 E MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-3010
Mailing Address - Country:US
Mailing Address - Phone:210-320-0979
Mailing Address - Fax:866-533-2028
Practice Address - Street 1:4940 BROADWAY ST
Practice Address - Street 2:STE 118
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-5747
Practice Address - Country:US
Practice Address - Phone:210-320-0979
Practice Address - Fax:866-533-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80988133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty