Provider Demographics
NPI:1194836692
Name:HOFFMAN, JACQUELYN J (RD CDE)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:J
Last Name:HOFFMAN
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3823
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:713 TROY SCHENECTADY RD
Practice Address - Street 2:SUITE 218
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2490
Practice Address - Country:US
Practice Address - Phone:518-782-3839
Practice Address - Fax:518-782-3761
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005808133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB1610Medicare PIN
NYRB1048Medicare PIN