Provider Demographics
NPI:1164019188
Name:LICHTEN, JO (PHD, RDN)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:
Last Name:LICHTEN
Suffix:
Gender:F
Credentials:PHD, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86135 HAMPTON BAYS DR
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-8130
Mailing Address - Country:US
Mailing Address - Phone:954-235-0371
Mailing Address - Fax:
Practice Address - Street 1:86135 HAMPTON BAYS DR
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-8130
Practice Address - Country:US
Practice Address - Phone:954-235-0371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLR592040133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered