Healthcare Provider Details

I. General information

NPI: 1669405932
Provider Name (Legal Business Name): JEAN R HALFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 E 25TH ST
IDAHO FALLS ID
83404-7542
US

IV. Provider business mailing address

2220 E 25TH ST
IDAHO FALLS ID
83404-7542
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-1122
  • Fax: 208-523-2582
Mailing address:
  • Phone: 208-523-1122
  • Fax: 208-523-2582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number369684
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: