Healthcare Provider Details

I. General information

NPI: 1760897193
Provider Name (Legal Business Name): JENNIFER SMITH RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 06/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7810 BALLANTYNE COMMONS PKWY SUITE 200
CHARLOTTE NC
28277-3415
US

IV. Provider business mailing address

7810 BALLANTYNE COMMONS PKWY SUITE 200
CHARLOTTE NC
28277-3415
US

V. Phone/Fax

Practice location:
  • Phone: 704-995-3434
  • Fax: 704-626-3339
Mailing address:
  • Phone: 704-995-3434
  • Fax: 704-626-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL004412
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: