Provider Demographics
NPI:1114587300
Name:GROSSE, JILLIAN LEE (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:LEE
Last Name:GROSSE
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 PALOMINO LANE NUTRITION IN MOTION, LLC
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110
Mailing Address - Country:US
Mailing Address - Phone:603-518-5859
Mailing Address - Fax:603-606-1032
Practice Address - Street 1:80 PALOMINO LANE NUTRITION IN MOTION, LLC
Practice Address - Street 2:SUITE 101
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110
Practice Address - Country:US
Practice Address - Phone:603-518-5859
Practice Address - Fax:603-606-1032
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4286133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered