Healthcare Provider Details

I. General information

NPI: 1386829844
Provider Name (Legal Business Name): JACKIE R GRIFFITHS RD,LN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4474 23RD AVE S STE M
FARGO ND
58104-8795
US

IV. Provider business mailing address

105 EVERGREEN CIR
WEST FARGO ND
58078-1201
US

V. Phone/Fax

Practice location:
  • Phone: 701-282-2635
  • Fax:
Mailing address:
  • Phone: 701-866-9352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number736
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number736
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: