Provider Demographics
NPI:1013462993
Name:LEET, JACLYN DANIELLE (RDN)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:DANIELLE
Last Name:LEET
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BROTHERTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-4801
Mailing Address - Country:US
Mailing Address - Phone:973-919-7330
Mailing Address - Fax:
Practice Address - Street 1:42 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:NJ
Practice Address - Zip Code:07403-1729
Practice Address - Country:US
Practice Address - Phone:973-919-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86083824133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered