Provider Demographics
NPI:1619731213
Name:THOMAS, JAISA (RD, LD)
Entity type:Individual
Prefix:
First Name:JAISA
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
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 1:3104 GRASSHOPPER WAY
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-0458
Mailing Address - Country:US
Mailing Address - Phone:405-445-8977
Mailing Address - Fax:
Practice Address - Street 1:7 NE 6TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-1801
Practice Address - Country:US
Practice Address - Phone:405-445-8977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2935133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered