Healthcare Provider Details

I. General information

NPI: 1366279408
Provider Name (Legal Business Name): JENNIFER VITRY DCN(C), MS, CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 S DORGENOIS ST
NEW ORLEANS LA
70119-6424
US

IV. Provider business mailing address

8922 BIRCH ST
NEW ORLEANS LA
70118-1406
US

V. Phone/Fax

Practice location:
  • Phone: 504-905-8663
  • Fax: 504-555-0212
Mailing address:
  • Phone: 504-905-8663
  • Fax: 504-555-0212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX6027
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: