Provider Demographics
NPI:1629201462
Name:DWYER, JACQUELINE (RD, CDE)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:DWYER
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1179 CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1807
Mailing Address - Country:US
Mailing Address - Phone:484-919-7480
Mailing Address - Fax:
Practice Address - Street 1:211 S 9TH ST
Practice Address - Street 2:SUITE 600
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19107-6810
Practice Address - Country:US
Practice Address - Phone:215-955-0453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADNOO1179133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered