Provider Demographics
NPI:1790105039
Name:WASS, JENELLE (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:
Last Name:WASS
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 BRICKHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-1492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 BRICKHAVEN DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-1492
Practice Address - Country:US
Practice Address - Phone:919-513-3698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003945133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered