Healthcare Provider Details

I. General information

NPI: 1043934086
Provider Name (Legal Business Name): JESSICA JASMINE WAITE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 MADISON AVE ATRAN BUILDING, FIRST FLOOR
NEW YORK NY
10029-6508
US

IV. Provider business mailing address

DEPARTMENT OF GENETICS & GENOMIC SCIENCES ONE GUSTAVE L LEVY PLACE, PO BOX 1497
NEW YORK NY
10029
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6947
  • Fax: 212-860-3316
Mailing address:
  • Phone: 212-241-0922
  • Fax: 212-860-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number010653-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number010653-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: