Healthcare Provider Details

I. General information

NPI: 1215288410
Provider Name (Legal Business Name): MS. JENNIFER MELTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13601 PRESTON RD SUITE 415W
DALLAS TX
75240
US

IV. Provider business mailing address

13601 PRESTON RD SUITE 415W
DALLAS TX
75240
US

V. Phone/Fax

Practice location:
  • Phone: 972-432-6550
  • Fax: 214-261-2217
Mailing address:
  • Phone: 972-432-6550
  • Fax: 214-261-2217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1016859
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: