Provider Demographics
NPI:1932928082
Name:GONZALES, JEFFREY DANIEL (RD, LD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DANIEL
Last Name:GONZALES
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 GENERAL KRUEGER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4616
Mailing Address - Country:US
Mailing Address - Phone:210-548-2879
Mailing Address - Fax:
Practice Address - Street 1:366 FM 1488 RD APT 1155
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-4380
Practice Address - Country:US
Practice Address - Phone:210-548-2879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86490133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered