Provider Demographics
NPI:1215161104
Name:JASTROW, SUSAN THOMAS (RD, LD, CDE)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:THOMAS
Last Name:JASTROW
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 PT RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:ROUND MOUNTAIN
Mailing Address - State:TX
Mailing Address - Zip Code:78663-5990
Mailing Address - Country:US
Mailing Address - Phone:512-466-4407
Mailing Address - Fax:830-825-2400
Practice Address - Street 1:1242 PT RANCH RD
Practice Address - Street 2:
Practice Address - City:ROUND MOUNTAIN
Practice Address - State:TX
Practice Address - Zip Code:78663-5990
Practice Address - Country:US
Practice Address - Phone:512-466-4407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-07
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04706133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered