Provider Demographics
NPI:1467774158
Name:SPORE, JENNIFER ANN (RD)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:ANN
Last Name:SPORE
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 1:624 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2955
Mailing Address - Country:US
Mailing Address - Phone:870-424-1425
Mailing Address - Fax:870-424-1355
Practice Address - Street 1:624 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2955
Practice Address - Country:US
Practice Address - Phone:870-424-1424
Practice Address - Fax:870-424-1355
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1145133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered