Healthcare Provider Details

I. General information

NPI: 1518242908
Provider Name (Legal Business Name): JULIE ANN JENSEN DIETICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE ANN ERTL

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 FLORMANN ST
RAPID CITY SD
57701
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTEN MEDICAL STAFF SERVICES
RAPID CITY SD
57701-6000
US

V. Phone/Fax

Practice location:
  • Phone: 605-718-3300
  • Fax: 605-718-3426
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number0380
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: