Healthcare Provider Details

I. General information

NPI: 1629201462
Provider Name (Legal Business Name): JACQUELINE DWYER RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S 9TH ST SUITE 600
PHILA PA
19107-6810
US

IV. Provider business mailing address

1179 CLEVELAND RD
BLUE BELL PA
19422-1807
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-0453
  • Fax:
Mailing address:
  • Phone: 484-919-7480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDNOO1179
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: