Provider Demographics
NPI:1578062097
Name:UNRUH, JEN (CNS, LDN)
Entity Type:Individual
Prefix:
First Name:JEN
Middle Name:
Last Name:UNRUH
Suffix:
Gender:F
Credentials:CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12600 PIEDMONT RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-9334
Mailing Address - Country:US
Mailing Address - Phone:240-750-0058
Mailing Address - Fax:
Practice Address - Street 1:12600 PIEDMONT RD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-9334
Practice Address - Country:US
Practice Address - Phone:240-750-0058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-10
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4348133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist