Provider Demographics
NPI:1336382035
Name:ERDOS, JACQUELINE BALLOU (MS, RD, CSSD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:BALLOU
Last Name:ERDOS
Suffix:
Gender:F
Credentials:MS, RD, CSSD, CDN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:RENEE
Other - Last Name:BALLOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:ONE AUTUMN STREET ROOM 455
Mailing Address - Street 2:CHILDRENS HOSPITAL BOSTON,
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-355-6097
Mailing Address - Fax:617-730-0183
Practice Address - Street 1:40 CROSS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-4647
Practice Address - Country:US
Practice Address - Phone:203-229-2000
Practice Address - Fax:203-840-3153
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1753133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered