Provider Demographics
NPI:1285221127
Name:HENRY, JULIA MICHELLE
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:MICHELLE
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:MICHELLE
Other - Last Name:LASSEN, BURKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3324 KEENES EDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6660
Mailing Address - Country:US
Mailing Address - Phone:417-860-9994
Mailing Address - Fax:
Practice Address - Street 1:3324 KEENES EDGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6660
Practice Address - Country:US
Practice Address - Phone:417-860-9994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026927133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered