Provider Demographics
NPI:1114221769
Name:MACDONALD, JENNIFER LEE (MSRD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SYLVAN LN
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-8420
Mailing Address - Country:US
Mailing Address - Phone:603-494-9310
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:617-323-6783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2011-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3120133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered