Provider Demographics
NPI:1073748349
Name:CLARK, JULIE W (MS, RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:W
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:IA
Mailing Address - Zip Code:50129-1920
Mailing Address - Country:US
Mailing Address - Phone:515-386-4153
Mailing Address - Fax:515-386-0364
Practice Address - Street 1:106 W WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129-1920
Practice Address - Country:US
Practice Address - Phone:515-386-4153
Practice Address - Fax:515-386-0364
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1002133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered