MEDICARE: MRS. JENNIFER KRASEVEC FORD RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	LD003195	GA

General Provider Information

NPI Number	:	1750513529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER KRASEVEC FORD RD

Provider Business Mailing Address
First Line	:	3508 BLACKBERRY LN SE
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30094-3529
Country	:	US
Telephone Number	:	770-313-2188
Fax Number	:

Provider Business Practice Location Address
First Line	:	2215 EXCHANGE PL SE
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30013-6723
Country	:	US
Telephone Number	:	770-922-3522
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2009
Last Update Date	:	08/12/2009

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