Healthcare Provider Details

I. General information

NPI: 1770817041
Provider Name (Legal Business Name): JENNILYN JACKMAN BAPTISTE MS, RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2009
Last Update Date: 09/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1864 CLOVE RD SUITE D
STATEN ISLAND NY
10304-1631
US

IV. Provider business mailing address

PO BOX 320648
BROOKLYN NY
11232-0648
US

V. Phone/Fax

Practice location:
  • Phone: 347-242-9804
  • Fax: 718-981-4580
Mailing address:
  • Phone: 347-242-9804
  • Fax: 718-981-4580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number003629-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number003629-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number003629-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: