Provider Demographics
NPI:1497177992
Name:DALE, JENNIFER WYNNE BOPP (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:WYNNE BOPP
Last Name:DALE
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 S MERCY RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-0419
Mailing Address - Country:US
Mailing Address - Phone:602-770-7611
Mailing Address - Fax:
Practice Address - Street 1:4904 S POWER RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-3609
Practice Address - Country:US
Practice Address - Phone:602-770-7611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ968353133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered