Provider Demographics
NPI:1316313018
Name:WALSH, JENNIFER KIM (MS RD CDN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KIM
Last Name:WALSH
Suffix:
Gender:F
Credentials:MS RD CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 MAIN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1080
Mailing Address - Country:US
Mailing Address - Phone:203-750-7400
Mailing Address - Fax:
Practice Address - Street 1:761 MAIN AVE STE 200
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1080
Practice Address - Country:US
Practice Address - Phone:203-750-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1769133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered