MEDICARE: MS. JACQUELYN ELAINE WELLS R.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	D0594	MS

General Provider Information

NPI Number	:	1144350281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACQUELYN ELAINE WELLS R.D.

Provider Business Mailing Address
First Line	:	103 MAGNOLIA WAY
Second Line	:
City	:	PEARL
State	:	MS
Zip	:	39208-3366
Country	:	US
Telephone Number	:	601-933-4548
Fax Number	:

Provider Business Practice Location Address
First Line	:	570 EAST WOODROW WILSON
Second Line	:	WIC CENTRAL OFFICE
City	:	JACKSON
State	:	MS
Zip	:	39215-1700
Country	:	US
Telephone Number	:	601-987-4666
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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