Provider Demographics
NPI:1306507207
Name:BURDEOS, JOHNA JIMENEZ (RD)
Entity type:Individual
Prefix:
First Name:JOHNA
Middle Name:JIMENEZ
Last Name:BURDEOS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 GREENTHREAD
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6370
Mailing Address - Country:US
Mailing Address - Phone:626-524-8564
Mailing Address - Fax:
Practice Address - Street 1:2226 GREENTHREAD
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6370
Practice Address - Country:US
Practice Address - Phone:626-524-8564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2025-01-09
Deactivation Date:2022-02-28
Deactivation Code:
Reactivation Date:2025-01-09
Provider Licenses
StateLicense IDTaxonomies
911826133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
911826OtherCOMMISSION ON DIETETIC REGISTRATION
TXDT84323OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION