Provider Demographics
NPI:1063726347
Name:TANE, JACLYN S (RD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:S
Last Name:TANE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:216 WILLIS AVE
Mailing Address - Street 2:STE 001
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2125
Mailing Address - Country:US
Mailing Address - Phone:516-801-0022
Mailing Address - Fax:516-277-1533
Practice Address - Street 1:216 WILLIS AVE
Practice Address - Street 2:STE 001
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2125
Practice Address - Country:US
Practice Address - Phone:516-801-0022
Practice Address - Fax:516-277-1533
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY006416133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist