Provider Demographics
NPI:1679088637
Name:STEVENS, JACQUELINE MATTE (MS, RDN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MATTE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MATTE
Other - Last Name:WAINORIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26 MUNROE LN
Mailing Address - Street 2:
Mailing Address - City:TOPSHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04086-1229
Mailing Address - Country:US
Mailing Address - Phone:207-649-8605
Mailing Address - Fax:
Practice Address - Street 1:54 CUMBERLAND ST STE 5
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-1829
Practice Address - Country:US
Practice Address - Phone:207-387-0108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1228133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered