Provider Demographics
NPI:1487312351
Name:COTUMACCIO, JACQUELINE (RD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:COTUMACCIO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 HIGHFIELD CT
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-5713
Mailing Address - Country:US
Mailing Address - Phone:516-512-4076
Mailing Address - Fax:
Practice Address - Street 1:55 CUTTERMILL RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK PLAZA
Practice Address - State:NY
Practice Address - Zip Code:11021-3259
Practice Address - Country:US
Practice Address - Phone:516-751-5736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86209519133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered