Provider Demographics
NPI:1922102110
Name:GARY, JENNIFER ASHLEY (RD LD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ASHLEY
Last Name:GARY
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ASHLEY
Other - Last Name:RAMSEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2929 CALDER ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1845
Mailing Address - Country:US
Mailing Address - Phone:409-833-9797
Mailing Address - Fax:409-654-6886
Practice Address - Street 1:3570 COLLEGE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4683
Practice Address - Country:US
Practice Address - Phone:409-833-9797
Practice Address - Fax:409-654-6909
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX967243133V00000X
TXDT80316133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00794645Medicare PIN
TX8L6483Medicare Oscar/Certification