Provider Demographics
NPI:1083250187
Name:JENKINS, HEATHER RUTHANN (RDN,LD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RUTHANN
Last Name:JENKINS
Suffix:
Gender:F
Credentials:RDN,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 CHERRY TREE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-8016
Mailing Address - Country:US
Mailing Address - Phone:662-394-1789
Mailing Address - Fax:
Practice Address - Street 1:2646 CHERRY TREE DR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8016
Practice Address - Country:US
Practice Address - Phone:662-394-1789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-23
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0813133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered