Provider Demographics
NPI:1477213395
Name:MINNAERT, JEFFREY DEAN
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DEAN
Last Name:MINNAERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 EAST BILL FARR DRIVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803
Mailing Address - Country:US
Mailing Address - Phone:317-988-2808
Mailing Address - Fax:
Practice Address - Street 1:5080 EAST BILL FARR DRIVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803
Practice Address - Country:US
Practice Address - Phone:317-988-2808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA099803133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered