Provider Demographics
NPI:1679866909
Name:FITZGIBBON, JENNIFER LYN (MS RD CDN)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:LYN
Last Name:FITZGIBBON
Suffix:
Gender:F
Credentials:MS RD CDN
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Mailing Address - Street 1:3 EDMUND D PELLEGRINO RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-1008
Mailing Address - Country:US
Mailing Address - Phone:631-638-0851
Mailing Address - Fax:631-638-0850
Practice Address - Street 1:3 EDMUND D PELLEGRINO RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-1008
Practice Address - Country:US
Practice Address - Phone:631-638-0851
Practice Address - Fax:631-638-0850
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY0059291133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered