Provider Demographics
NPI:1609929108
Name:MAXWELL, JEAN L (MS RD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:L
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 PORTVIEW AVE APT B
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23503-1520
Mailing Address - Country:US
Mailing Address - Phone:757-589-4293
Mailing Address - Fax:
Practice Address - Street 1:256 PORTVIEW AVE APT B
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23503-1520
Practice Address - Country:US
Practice Address - Phone:757-589-4293
Practice Address - Fax:833-740-4130
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA959775133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered