Provider Demographics
NPI:1548206147
Name:BEDWELL, JACQUELYN (RD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:BEDWELL
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 1:3501 CHESTERBROOK CT
Mailing Address - Street 2:APT 618
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1296
Mailing Address - Country:US
Mailing Address - Phone:804-387-3200
Mailing Address - Fax:
Practice Address - Street 1:MG886A.4 DTHC CORRIDOR # 8
Practice Address - Street 2:5801 ARMY PENTAGON
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20310-5801
Practice Address - Country:US
Practice Address - Phone:703-692-8891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX2605133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
931718OtherCDR
MDDX2605OtherLDN