Provider Demographics
NPI:1952639114
Name:GORMAN, JENNIFER L (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8206 VICKSBURG AVE
Mailing Address - Street 2:STE A
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-4015
Mailing Address - Country:US
Mailing Address - Phone:806-401-0460
Mailing Address - Fax:855-490-4610
Practice Address - Street 1:8206 VICKSBURG AVE
Practice Address - Street 2:STE A
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-4015
Practice Address - Country:US
Practice Address - Phone:806-401-0460
Practice Address - Fax:855-490-4610
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81252133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered