Healthcare Provider Details

I. General information

NPI: 1053733428
Provider Name (Legal Business Name): JENNIFER BEAZER RDN LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2014
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CONWAY DR STE 200
KALISPELL MT
59901-3153
US

IV. Provider business mailing address

248 1ST AVE W UNIT 1342
KALISPELL MT
59903-7056
US

V. Phone/Fax

Practice location:
  • Phone: 406-751-4188
  • Fax:
Mailing address:
  • Phone: 208-789-9668
  • Fax: 208-381-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number79779
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberD470
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code133VN1401X
TaxonomyPediatric Critical Care Nutrition Registered Dietitian
License Number79779
License Number StateMT
# 4
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number79779
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: