Healthcare Provider Details

I. General information

NPI: 1659702876
Provider Name (Legal Business Name): JESSICA LEE ALTLAND RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HATFIELD LN SUITE 107
GOSHEN NY
10924-6766
US

IV. Provider business mailing address

5 PEVERO DR UNIT 3
VERNON NJ
07462-2570
US

V. Phone/Fax

Practice location:
  • Phone: 845-651-1400
  • Fax:
Mailing address:
  • Phone: 201-297-2197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number007920
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: