Provider Demographics
NPI:1053767657
Name:HALCOM, JAMIE
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:HALCOM
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 1:1445 E PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06870-1379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1445 E PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-1379
Practice Address - Country:US
Practice Address - Phone:203-835-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1000003133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered