Provider Demographics
NPI:1558643924
Name:KASSOFF, JACLYN A (RD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:KASSOFF
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 1:844 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-4531
Mailing Address - Country:US
Mailing Address - Phone:516-359-3689
Mailing Address - Fax:
Practice Address - Street 1:2053 BELLMORE AVE
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5603
Practice Address - Country:US
Practice Address - Phone:516-679-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1059289133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered