Provider Demographics
NPI:1275710527
Name:WASS, JERILYN MARIE (LRD)
Entity Type:Individual
Prefix:MRS
First Name:JERILYN
Middle Name:MARIE
Last Name:WASS
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6827 88TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:STARKWEATHER
Mailing Address - State:ND
Mailing Address - Zip Code:58377-9330
Mailing Address - Country:US
Mailing Address - Phone:701-292-4163
Mailing Address - Fax:
Practice Address - Street 1:6827 88TH AVE NE
Practice Address - Street 2:
Practice Address - City:STARKWEATHER
Practice Address - State:ND
Practice Address - Zip Code:58377-9330
Practice Address - Country:US
Practice Address - Phone:701-292-4163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND630133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered