Provider Demographics
NPI:1245568526
Name:BUKER, JENNIFER C (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:BUKER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:C
Other - Last Name:WADNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:3314 E EXACTA LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-7197
Mailing Address - Country:US
Mailing Address - Phone:208-994-9739
Mailing Address - Fax:
Practice Address - Street 1:3314 E EXACTA LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-7197
Practice Address - Country:US
Practice Address - Phone:208-994-9739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID974093133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered