Provider Demographics
NPI:1558838672
Name:MIMKHA, JENNIFER (MPH RD LDN CLC CLT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MIMKHA
Suffix:
Gender:F
Credentials:MPH RD LDN CLC CLT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11850 DR MARTIN LUTHER KING ST N APT 12304
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1631
Mailing Address - Country:US
Mailing Address - Phone:484-620-2785
Mailing Address - Fax:
Practice Address - Street 1:11850 DR MARTIN LUTHER KING ST N APT 12304
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1631
Practice Address - Country:US
Practice Address - Phone:484-620-2785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6949133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered