Provider Demographics
NPI:1528711389
Name:FANG, JENIFER LUNA (MCN, RDN, LD)
Entity type:Individual
Prefix:
First Name:JENIFER
Middle Name:LUNA
Last Name:FANG
Suffix:
Gender:F
Credentials:MCN, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 GASTON AVE STE 965
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2036
Mailing Address - Country:US
Mailing Address - Phone:972-817-6050
Mailing Address - Fax:
Practice Address - Street 1:3417 GASTON AVE STE 965
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2036
Practice Address - Country:US
Practice Address - Phone:972-817-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86198088133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered