Provider Demographics
NPI:1003867920
Name:FILLER, JENNIFER ELIZABETH (RD, CD-N, CDE)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:FILLER
Suffix:
Gender:F
Credentials:RD, CD-N, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 1/2 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4905
Mailing Address - Country:US
Mailing Address - Phone:631-766-9382
Mailing Address - Fax:
Practice Address - Street 1:240 WILLOUGHBY ST
Practice Address - Street 2:SUITE 11E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5465
Practice Address - Country:US
Practice Address - Phone:718-250-8866
Practice Address - Fax:718-250-6705
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2011-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006101-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03095723Medicaid
NY9562E1Medicare PIN