Provider Demographics
NPI:1578085320
Name:HENDERSON, JENNY LYNETTE (RD)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:LYNETTE
Last Name:HENDERSON
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 1:33 PARK CIR
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-4805
Mailing Address - Country:US
Mailing Address - Phone:435-828-5414
Mailing Address - Fax:435-781-6886
Practice Address - Street 1:150 W 100 N
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2036
Practice Address - Country:US
Practice Address - Phone:435-781-6874
Practice Address - Fax:435-781-6886
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10877133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty