Provider Demographics
NPI:1912276411
Name:KOVALICK, JENNIFER L (MS, RDN, CDN)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:KOVALICK
Suffix:
Gender:F
Credentials:MS, RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WEHRLE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7381
Mailing Address - Country:US
Mailing Address - Phone:716-912-9103
Mailing Address - Fax:716-276-3909
Practice Address - Street 1:2801 WEHRLE DR STE 4
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7381
Practice Address - Country:US
Practice Address - Phone:716-912-9103
Practice Address - Fax:716-276-3909
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY927796133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY48 006121OtherCDN
NY927796OtherREGISTERED DIETITIAN NUMBER