Provider Demographics
NPI:1558550962
Name:GANLY, JENNIFER D (LD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:GANLY
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:652F CENTRAL AVE # F
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-3414
Mailing Address - Country:US
Mailing Address - Phone:603-749-2346
Mailing Address - Fax:603-953-0066
Practice Address - Street 1:652F CENTRAL AVE # F
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-3414
Practice Address - Country:US
Practice Address - Phone:603-749-2346
Practice Address - Fax:603-953-0066
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0493133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered