Provider Demographics
NPI:1639452162
Name:GROMOLL, JASON E (RD, CDN)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:E
Last Name:GROMOLL
Suffix:
Gender:M
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 SPRINGDALE WAY
Mailing Address - Street 2:
Mailing Address - City:ROTTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12306-5606
Mailing Address - Country:US
Mailing Address - Phone:518-250-3898
Mailing Address - Fax:
Practice Address - Street 1:206 SPRINGDALE WAY
Practice Address - Street 2:
Practice Address - City:ROTTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12306-5606
Practice Address - Country:US
Practice Address - Phone:518-250-3898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007243133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered