Healthcare Provider Details

I. General information

NPI: 1558607630
Provider Name (Legal Business Name): JENNA ARIEL STOCK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 WILLOW AVE CLINICAL NUTRITION OFFICE 6 SOUTH
HOBOKEN NJ
07030-3808
US

IV. Provider business mailing address

308 WILLOW AVE CLINICAL NUTRITION OFFICE 6 SOUTH
HOBOKEN NJ
07030-3808
US

V. Phone/Fax

Practice location:
  • Phone: 201-418-1143
  • Fax:
Mailing address:
  • Phone: 201-418-1143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1059113
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: