Provider Demographics
NPI:1003797044
Name:JACO, JUSTON WILLIAM (CNS)
Entity type:Individual
Prefix:
First Name:JUSTON
Middle Name:WILLIAM
Last Name:JACO
Suffix:
Gender:M
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9260 REGENTS RD APT E
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1439
Mailing Address - Country:US
Mailing Address - Phone:269-352-1105
Mailing Address - Fax:
Practice Address - Street 1:9260 REGENTS RD APT E
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1439
Practice Address - Country:US
Practice Address - Phone:269-352-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
188087133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty