Provider Demographics
NPI:1659950822
Name:KIERNAN, JACLYN A (RDN)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 SMITHTOWN BYP
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5005
Mailing Address - Country:US
Mailing Address - Phone:631-406-9323
Mailing Address - Fax:
Practice Address - Street 1:496 SMITHTOWN BYP STE 204
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5011
Practice Address - Country:US
Practice Address - Phone:631-371-3825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86075293133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered