Provider Demographics
NPI:1750513529
Name:FORD, JENNIFER KRASEVEC (RD)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KRASEVEC
Last Name:FORD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3508 BLACKBERRY LN SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3529
Mailing Address - Country:US
Mailing Address - Phone:770-313-2188
Mailing Address - Fax:
Practice Address - Street 1:2215 EXCHANGE PL SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6723
Practice Address - Country:US
Practice Address - Phone:770-922-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003195133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered