Provider Demographics
NPI:1598894578
Name:DEVEREAUX, JESSICA LYNN (RD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:DEVEREAUX
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 1:87 GREAT ROCK DR
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-1850
Mailing Address - Country:US
Mailing Address - Phone:631-886-1199
Mailing Address - Fax:
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1928
Practice Address - Country:US
Practice Address - Phone:631-474-6492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered