Provider Demographics
NPI:1477099695
Name:KRYVICKY, JENNIFERLYN (CN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFERLYN
Middle Name:
Last Name:KRYVICKY
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2446 PRINCETON RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3908
Mailing Address - Country:US
Mailing Address - Phone:248-895-3405
Mailing Address - Fax:
Practice Address - Street 1:2446 PRINCETON RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3908
Practice Address - Country:US
Practice Address - Phone:248-895-3405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINA133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist