Provider Demographics
NPI:1174598957
Name:JASONIDES, ANNA (RD)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:JASONIDES
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:PO BOX 425789
Mailing Address - Street 2:MEDICAL E23-395
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-0015
Mailing Address - Country:US
Mailing Address - Phone:617-253-0556
Mailing Address - Fax:
Practice Address - Street 1:77 MASS AVE
Practice Address - Street 2:MEDICAL E23-395
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4301
Practice Address - Country:US
Practice Address - Phone:617-253-0556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA723922133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMT0693Medicare ID - Type Unspecified