Provider Demographics
NPI:1003942533
Name:LUSSIER, JEAN M (RD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:LUSSIER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 HAVERHILL STREET
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841
Mailing Address - Country:US
Mailing Address - Phone:978-686-0090
Mailing Address - Fax:978-687-3726
Practice Address - Street 1:34 HAVERHILL STREET
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841
Practice Address - Country:US
Practice Address - Phone:978-686-0090
Practice Address - Fax:978-687-3726
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1015133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALUMTO519Medicare ID - Type Unspecified