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General NPI Number Information
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NPI Number | 1447400437
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Entity Type | Individual
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Provider Name | JACQUELINE MARIE HUMPHERYS RD
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Gender | Female
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Dates
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Enumeration Date | 09/25/2008
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Last Update Date | 09/25/2008
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Provider Practice Location Address
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Address Line | 5183 SADDLE STRAP WAY
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City | PINETOP
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State | AZ
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Zip | 85935-7535
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Country | US
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Telephone | 928-369-1111
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Fax |
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Provider Business Mailing Address
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Address Line | 5183 SADDLE STRAP WAY
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City | PINETOP
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State | AZ
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Zip | 85935-7535
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Country | US
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Telephone | 928-369-1111
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 807654
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License Number State | ID
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