MEDICARE: KELLI R JENNINGS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1194817742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLI R JENNINGS

Provider Business Mailing Address
First Line	:	PO BOX 2074
Second Line	:	142 SHAVANO ST.
City	:	CRESTED BUTTE
State	:	CO
Zip	:	81224-2074
Country	:	US
Telephone Number	:	970-349-0767
Fax Number	:

Provider Business Practice Location Address
First Line	:	142 SHAVANO
Second Line	:
City	:	CRESTED BUTTE
State	:	CO
Zip	:	81224
Country	:	US
Telephone Number	:	970-349-0767
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. KELLI RAE JENNINGS
Credential	:	RD
Telephone Number	:	970-349-0767

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	06/20/2008

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