MEDICARE: JENNIFER DAMOUR

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	2002021884	MO

General Provider Information

NPI Number	:	1629465547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DAMOUR

Provider Business Mailing Address
First Line	:	1905 W 32ND ST STE 303
Second Line	:
City	:	JOPLIN
State	:	MO
Zip	:	64804-1512
Country	:	US
Telephone Number	:	417-782-4100
Fax Number	:	417-782-4116

Provider Business Practice Location Address
First Line	:	1905 W 32ND ST STE 303
Second Line	:
City	:	JOPLIN
State	:	MO
Zip	:	64804-1512
Country	:	US
Telephone Number	:	417-782-4100
Fax Number	:	417-782-4116

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

Provider Enumeration Date	:	04/17/2015
Last Update Date	:	04/17/2015

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