Provider Demographics
NPI:1497982490
Name:GREGOLINE, JENNIFER LYNN (RD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:GREGOLINE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6625 NETWORK WAY STE 100
Mailing Address - Street 2:INTECH 11
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-0007
Mailing Address - Country:US
Mailing Address - Phone:317-275-7010
Mailing Address - Fax:317-275-7012
Practice Address - Street 1:6625 NETWORK WAY STE 100
Practice Address - Street 2:INTECH 11
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-0007
Practice Address - Country:US
Practice Address - Phone:317-275-7010
Practice Address - Fax:317-275-7012
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN913931133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered