Provider Demographics
NPI:1174234363
Name:VALENTINE, JESSIE (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:MISS
First Name:JESSIE
Middle Name:
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 LUDLAM AVE
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-3202
Mailing Address - Country:US
Mailing Address - Phone:516-233-0025
Mailing Address - Fax:
Practice Address - Street 1:28 LUDLAM AVE
Practice Address - Street 2:
Practice Address - City:BAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11709-3202
Practice Address - Country:US
Practice Address - Phone:516-233-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
086072251133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered