Provider Demographics
NPI:1972822328
Name:DELUCA, JENNIFER (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DELUCA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5175 STONEHAVEN VW
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-0575
Mailing Address - Country:US
Mailing Address - Phone:678-978-7478
Mailing Address - Fax:
Practice Address - Street 1:5175 STONEHAVEN VW
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-0575
Practice Address - Country:US
Practice Address - Phone:678-978-7478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003508133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered