Healthcare Provider Details

I. General information

NPI: 1194817742
Provider Name (Legal Business Name): KELLI R JENNINGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 SHAVANO
CRESTED BUTTE CO
81224
US

IV. Provider business mailing address

PO BOX 2074 142 SHAVANO ST.
CRESTED BUTTE CO
81224-2074
US

V. Phone/Fax

Practice location:
  • Phone: 970-349-0767
  • Fax:
Mailing address:
  • Phone: 970-349-0767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLI RAE JENNINGS
Title or Position: PRESIDENT
Credential: RD
Phone: 970-349-0767