Provider Demographics
NPI:1093087355
Name:SOUTHARD, JENNIFER (MS, RD/LD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:MS, RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 S BOULEVARD STE 127
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5308
Mailing Address - Country:US
Mailing Address - Phone:405-960-3120
Mailing Address - Fax:
Practice Address - Street 1:3120 S BOULEVARD STE 127
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5308
Practice Address - Country:US
Practice Address - Phone:405-960-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1720133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093087355OtherNPI