Healthcare Provider Details

I. General information

NPI: 1558829499
Provider Name (Legal Business Name): JENNIFER CUDDEBACK RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 CLAYTON RD
RICHMOND HEIGHTS MO
63117-1811
US

IV. Provider business mailing address

6420 CLAYTON RD
RICHMOND HEIGHTS MO
63117-1811
US

V. Phone/Fax

Practice location:
  • Phone: 314-768-8833
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2019006035
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: