Provider Demographics
NPI:1699462200
Name:JUNGBLUTH, ALEXANDRA JANE (RDN)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:JANE
Last Name:JUNGBLUTH
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BIRCH LEDGES DR
Mailing Address - Street 2:
Mailing Address - City:WEST BATH
Mailing Address - State:ME
Mailing Address - Zip Code:04530-6814
Mailing Address - Country:US
Mailing Address - Phone:415-302-7446
Mailing Address - Fax:
Practice Address - Street 1:50 BIRCH LEDGES DR
Practice Address - Street 2:
Practice Address - City:WEST BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-6814
Practice Address - Country:US
Practice Address - Phone:415-302-7446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1783133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered