Provider Demographics
NPI:1689490237
Name:REYNOSO, JONATHAN (RDN, LDN, CSCS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:M
Credentials:RDN, LDN, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7129 CREST RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-3944
Mailing Address - Country:US
Mailing Address - Phone:630-880-3388
Mailing Address - Fax:
Practice Address - Street 1:7129 CREST RD
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:IL
Practice Address - Zip Code:60561-3944
Practice Address - Country:US
Practice Address - Phone:630-880-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.011380133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered