Provider Demographics
NPI:1518491521
Name:LEASE, JENNIFER NICHOLE (RD, CDN)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:NICHOLE
Last Name:LEASE
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 MERRIFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-2911
Mailing Address - Country:US
Mailing Address - Phone:516-425-3637
Mailing Address - Fax:
Practice Address - Street 1:253 MERRIFIELD AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-2911
Practice Address - Country:US
Practice Address - Phone:516-425-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86014416133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered