Provider Demographics
NPI:1861415564
Name:CANGANELLI, JENNIFER L (RD, CDE)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CANGANELLI
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 HILLDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8223
Mailing Address - Country:US
Mailing Address - Phone:352-572-6503
Mailing Address - Fax:
Practice Address - Street 1:2900 E BARNETT RD STE 2
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8380
Practice Address - Country:US
Practice Address - Phone:541-789-5906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 3966133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL297594OtherAVMED VENDOR NUMBER
FL297594OtherAVMED VENDOR NUMBER