Provider Demographics
NPI:1962151621
Name:EHTESHAMI, JENNA (RD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:EHTESHAMI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1157 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-1830
Mailing Address - Country:US
Mailing Address - Phone:740-607-1354
Mailing Address - Fax:
Practice Address - Street 1:1157 S VINE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-1830
Practice Address - Country:US
Practice Address - Phone:740-607-1354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86013688133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered