Healthcare Provider Details

I. General information

NPI: 1255053682
Provider Name (Legal Business Name): JENNA STOKER RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

2041 E 2100 N
LAYTON UT
84040-7883
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-5317
  • Fax:
Mailing address:
  • Phone: 385-362-2128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number12937548-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: