Provider Demographics
NPI:1265860407
Name:FODOR, JACLYN (RD, LD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:FODOR
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:LYNNFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01940-1841
Mailing Address - Country:US
Mailing Address - Phone:781-580-9311
Mailing Address - Fax:
Practice Address - Street 1:80 PALOMINO LN
Practice Address - Street 2:SUITE 101
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6447
Practice Address - Country:US
Practice Address - Phone:603-518-5859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-25
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0685133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered