Provider Demographics
NPI:1629600523
Name:AMBROSE, JACQUELINE R (MA, RD, ADCES)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:R
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:MA, RD, ADCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:AYLETT
Mailing Address - State:VA
Mailing Address - Zip Code:23009-0566
Mailing Address - Country:US
Mailing Address - Phone:804-314-0409
Mailing Address - Fax:
Practice Address - Street 1:618 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-5000
Practice Address - Country:US
Practice Address - Phone:804-443-6179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA911825133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
20810009OtherASSOCIATION OF DIABETES CARE & EDUCATION SPECIALIST