Provider Demographics
NPI:1699432401
Name:WYMAN, JACQUELINE E (MS, RD, CDN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:E
Last Name:WYMAN
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:E
Other - Last Name:WYMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD, CDN
Mailing Address - Street 1:3 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2205
Mailing Address - Country:US
Mailing Address - Phone:917-797-7809
Mailing Address - Fax:
Practice Address - Street 1:3 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2205
Practice Address - Country:US
Practice Address - Phone:917-797-7809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Multi-Specialty