Provider Demographics
NPI:1023833340
Name:LEOS, JENNIFER P (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:P
Last Name:LEOS
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 1:2569 WOOD PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2196
Mailing Address - Country:US
Mailing Address - Phone:936-443-5371
Mailing Address - Fax:
Practice Address - Street 1:2569 WOOD PARK BLVD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2196
Practice Address - Country:US
Practice Address - Phone:936-443-5371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT80210133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered