Provider Demographics
NPI:1750475315
Name:ANDERSON, JEAN MARIE (RD, CDN,CDE,MS)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RD, CDN,CDE,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MIDDLEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2200
Mailing Address - Country:US
Mailing Address - Phone:631-261-4400
Mailing Address - Fax:
Practice Address - Street 1:79 MIDDLEVILLE RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2200
Practice Address - Country:US
Practice Address - Phone:631-261-4400
Practice Address - Fax:631-266-6018
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
805573133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000570-1OtherCERTIFIED DIETITIAN-NUTRI