Provider Demographics
NPI:1598094963
Name:LEITAO, JEANNIE MARIE (RD)
Entity Type:Individual
Prefix:MS
First Name:JEANNIE
Middle Name:MARIE
Last Name:LEITAO
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 1:2790 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2027
Mailing Address - Country:US
Mailing Address - Phone:860-430-9922
Mailing Address - Fax:860-633-9922
Practice Address - Street 1:2790 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2027
Practice Address - Country:US
Practice Address - Phone:860-430-9922
Practice Address - Fax:860-633-9922
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133NN1002X
CT000964133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education