Provider Demographics
NPI:1952037376
Name:LY, JENNIFER (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LY
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 1:1002 LAURELLEAF DR
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-2246
Mailing Address - Country:US
Mailing Address - Phone:512-228-2014
Mailing Address - Fax:
Practice Address - Street 1:1002 LAURELLEAF DR
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-2246
Practice Address - Country:US
Practice Address - Phone:512-228-2014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86130163133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered