Provider Demographics
NPI:1700145778
Name:WALSH, JENNIFER J (RD,CDN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:J
Last Name:WALSH
Suffix:
Gender:F
Credentials:RD,CDN
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:JO
Other - Last Name:WALSH-BARTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD,CDN
Mailing Address - Street 1:1913 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-3300
Mailing Address - Country:US
Mailing Address - Phone:516-987-7375
Mailing Address - Fax:631-588-1390
Practice Address - Street 1:1913 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-3300
Practice Address - Country:US
Practice Address - Phone:516-987-7375
Practice Address - Fax:631-588-1390
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005234-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered