Provider Demographics
NPI:1700699816
Name:DUMOLT, JERAD
Entity type:Individual
Prefix:
First Name:JERAD
Middle Name:
Last Name:DUMOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NASHUA ST APT 1409
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-1618
Mailing Address - Country:US
Mailing Address - Phone:281-636-9926
Mailing Address - Fax:
Practice Address - Street 1:732 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2309
Practice Address - Country:US
Practice Address - Phone:281-636-9926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALDN7037133VN1006X, 133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic