Provider Demographics
NPI:1205180379
Name:BASS, JENNIFER L (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BASS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-1508
Mailing Address - Country:US
Mailing Address - Phone:712-246-0092
Mailing Address - Fax:
Practice Address - Street 1:512 S FREMONT ST
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-1508
Practice Address - Country:US
Practice Address - Phone:712-246-0092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01746133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered