Provider Demographics
NPI:1396324117
Name:COLEMAN, JENICA L
Entity type:Individual
Prefix:
First Name:JENICA
Middle Name:L
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 NE 13TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-2859
Mailing Address - Country:US
Mailing Address - Phone:731-549-6091
Mailing Address - Fax:
Practice Address - Street 1:380 MCGILL PL NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1069
Practice Address - Country:US
Practice Address - Phone:731-549-6091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered