Provider Demographics
NPI:1023483757
Name:WARNER, JACQUELYN (RD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:WARNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JACQUIE
Other - Middle Name:
Other - Last Name:DONOHUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1449 CLEVELAND AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3525 MONTEREY DR
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-5275
Practice Address - Country:US
Practice Address - Phone:952-993-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3629133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered