Provider Demographics
NPI:1497947063
Name:TAVERAS, JENNIFER (RD,CDN,CDE)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:TAVERAS
Suffix:
Gender:F
Credentials:RD,CDN,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 PLAINFIELD LN
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3608
Mailing Address - Country:US
Mailing Address - Phone:516-510-5769
Mailing Address - Fax:
Practice Address - Street 1:5514 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5058
Practice Address - Country:US
Practice Address - Phone:516-510-5769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2011-0516133NN1002X
NY005680-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education