Provider Demographics
NPI:1821147604
Name:JUSTICE, JACQUELINE ANN (MS, CNS)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:MS, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 SIWANOY BLVD
Mailing Address - Street 2:
Mailing Address - City:EASTCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10709-3815
Mailing Address - Country:US
Mailing Address - Phone:914-961-5016
Mailing Address - Fax:914-961-5184
Practice Address - Street 1:126 SIWANOY BLVD
Practice Address - Street 2:
Practice Address - City:EASTCHESTER
Practice Address - State:NY
Practice Address - Zip Code:10709-3815
Practice Address - Country:US
Practice Address - Phone:914-961-5016
Practice Address - Fax:914-961-5184
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004970133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist