Healthcare Provider Details

I. General information

NPI: 1548877327
Provider Name (Legal Business Name): JEAN LIU MS, RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13635 CIMARRON AVE
GARDENA CA
90249-2499
US

IV. Provider business mailing address

13635 CIMARRON AVE
GARDENA CA
90249-2499
US

V. Phone/Fax

Practice location:
  • Phone: 617-657-9877
  • Fax: 866-657-4321
Mailing address:
  • Phone: 617-657-9877
  • Fax: 866-657-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number338334
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: