Provider Demographics
NPI:1063063295
Name:JAY, ALLISON (RD)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:JAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-4206
Mailing Address - Country:US
Mailing Address - Phone:419-603-3454
Mailing Address - Fax:
Practice Address - Street 1:4777 E OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3241
Practice Address - Country:US
Practice Address - Phone:313-369-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86004099133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86004099OtherCOMMISSION ON DIETETIC REGISTRATION