Provider Demographics
NPI:1629371265
Name:DAUGHERTY, JENNA LEE (RD)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:LEE
Last Name:DAUGHERTY
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 1:11101 LAKE AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-1113
Mailing Address - Country:US
Mailing Address - Phone:440-669-7356
Mailing Address - Fax:
Practice Address - Street 1:25550 CHAGRIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4640
Practice Address - Country:US
Practice Address - Phone:440-669-7356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-20
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered