Provider Demographics
NPI:1508635491
Name:WITHEY, JENNIFER (MSACN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WITHEY
Suffix:
Gender:F
Credentials:MSACN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 MOJAVE TRL
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4657
Mailing Address - Country:US
Mailing Address - Phone:318-332-0195
Mailing Address - Fax:
Practice Address - Street 1:122 N ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-2425
Practice Address - Country:US
Practice Address - Phone:832-580-2046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist