Healthcare Provider Details

I. General information

NPI: 1063808756
Provider Name (Legal Business Name): JENNIFER CHADBOURNE MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 RYE ST SUITE 305
PORTSMOUTH NH
03801-6829
US

IV. Provider business mailing address

15 RYE ST STE 305
PORTSMOUTH NH
03801-6846
US

V. Phone/Fax

Practice location:
  • Phone: 888-320-1776
  • Fax: 617-371-2950
Mailing address:
  • Phone: 888-320-1776
  • Fax: 617-507-8576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0734
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3686
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN00843
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: