Provider Demographics
NPI:1215688122
Name:BUFFONE, JAKE (RD)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BUFFONE
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 GRUBER ST APT B5
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-1033
Mailing Address - Country:US
Mailing Address - Phone:248-421-2666
Mailing Address - Fax:
Practice Address - Street 1:4800 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2677
Practice Address - Country:US
Practice Address - Phone:810-732-8336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered