Provider Demographics
NPI:1760557425
Name:SHANAHAN, JENNIFER J (RD, CDN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
Last Name:SHANAHAN
Suffix:
Gender:F
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 1:216 GLEN SUMMER RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-5025
Mailing Address - Country:US
Mailing Address - Phone:631-472-6717
Mailing Address - Fax:
Practice Address - Street 1:45 RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-6401
Practice Address - Country:US
Practice Address - Phone:631-941-2000
Practice Address - Fax:631-941-2010
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003715-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7483317OtherAETNA PROVIDER NUMBER
NYP2640809OtherOXFORD PROVIDER NUMBER
NY0114716OtherGHI PROVIDER NUMBER
NYAZ00898OtherMDNY PROVIDER NUMBER
NY2269089OtherUNITED HC PROVIDER NUMBER