Jesus Ivan Vazquez

Primary specialty

Registered Dietetic TechnicianTaxonomy code 136A00000X

License

86277429 Issued in FL

Practice address

100 N Lake St
Crescent City, FL 32112-2620

Phone

(386) 698-2222

NPI assigned

Oct 30, 2026

Last updated

Oct 30, 2026By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1793318400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1793318400000",
    "number": "1861390676",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "32044 2ND AVE",
            "city": "DELAND",
            "state": "FL",
            "postal_code": "327204853"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 N LAKE ST",
            "city": "CRESCENT CITY",
            "state": "FL",
            "postal_code": "321122620",
            "telephone_number": "386-698-2222"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VAZQUEZ",
        "first_name": "JESUS",
        "middle_name": "IVAN",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2026-10-30",
        "last_updated": "2026-10-30",
        "certification_date": "2026-10-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "136A00000X",
            "taxonomy_group": "",
            "desc": "Dietetic Technician, Registered",
            "state": "FL",
            "license": "86277429",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sunrise Primary Care Inc
• T R Suggs MD Medical Clinic PA
• Mark Erik Tallaksen, D.C.
• The Pavilion at Crescent Lake for Nursing and Rehabilitation, LLC (The Pavilion at Crescent Lake)
• Erica Varesi, LPN
• Vicktoria Amme' Williams, PTA

• Registered Dietetic Technician in Crescent City, FL
• Providers in Crescent City, FL by specialty
• Registered Dietetic Technician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 30, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.