Provider Demographics
NPI:1447400437
Name:HUMPHERYS, JACQUELINE MARIE (RD)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:HUMPHERYS
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 1:5183 SADDLE STRAP WAY
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-7535
Mailing Address - Country:US
Mailing Address - Phone:928-369-1111
Mailing Address - Fax:
Practice Address - Street 1:5183 SADDLE STRAP WAY
Practice Address - Street 2:
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-7535
Practice Address - Country:US
Practice Address - Phone:928-369-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID807654133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered