Healthcare Provider Details

I. General information

NPI: 1952832958
Provider Name (Legal Business Name): JACLYN VENTRE R.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 LIONEL ST
CLARK NJ
07066-2522
US

IV. Provider business mailing address

8 LIONEL ST
CLARK NJ
07066-2522
US

V. Phone/Fax

Practice location:
  • Phone: 646-662-1087
  • Fax:
Mailing address:
  • Phone: 646-662-1087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86021318
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: