Provider Demographics
NPI:1154809663
Name:SNYDER, JESSICA (RDN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SNYDER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:HUCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DTR
Mailing Address - Street 1:114 WAWBEEK AVE
Mailing Address - Street 2:
Mailing Address - City:TUPPER LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12986
Mailing Address - Country:US
Mailing Address - Phone:518-897-8859
Mailing Address - Fax:
Practice Address - Street 1:114 WAWBEEK AVE
Practice Address - Street 2:
Practice Address - City:TUPPER LAKE
Practice Address - State:NY
Practice Address - Zip Code:12986
Practice Address - Country:US
Practice Address - Phone:518-897-8859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
136A00000X
1102871133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered