Provider Demographics
NPI:1770221038
Name:MONTGOMERY, JEFFREY ADAM (RDN)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ADAM
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MORELAND AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-2810
Mailing Address - Country:US
Mailing Address - Phone:281-705-8649
Mailing Address - Fax:
Practice Address - Street 1:23 MORELAND AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-2810
Practice Address - Country:US
Practice Address - Phone:281-705-8649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86130922133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered