Provider Demographics
NPI:1053652602
Name:POPENHAGEN, JAIME L
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:L
Last Name:POPENHAGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HUNTERS RIDGE DR
Mailing Address - Street 2:#45
Mailing Address - City:GENOA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53128-2532
Mailing Address - Country:US
Mailing Address - Phone:815-276-8872
Mailing Address - Fax:
Practice Address - Street 1:112 ELIZABETH LN
Practice Address - Street 2:
Practice Address - City:GENOA CITY
Practice Address - State:WI
Practice Address - Zip Code:53128-2124
Practice Address - Country:US
Practice Address - Phone:262-279-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist