Provider Demographics
NPI:1982006375
Name:ANDERSON, JACQUELYN (RD, CDN)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:ALMONTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, CDN
Mailing Address - Street 1:2157 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-2648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2157 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2648
Practice Address - Country:US
Practice Address - Phone:716-862-1984
Practice Address - Fax:716-862-1228
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86010156133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered