Provider Demographics
NPI:1366813685
Name:MAGNAN, JACOB (RD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MAGNAN
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 BEAN RD
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-6830
Mailing Address - Country:US
Mailing Address - Phone:484-241-1189
Mailing Address - Fax:
Practice Address - Street 1:762 BEAN RD
Practice Address - Street 2:APARTMENT 2
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-6830
Practice Address - Country:US
Practice Address - Phone:484-241-1189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT074.0115928133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered