Provider Demographics
NPI:1578285078
Name:WELLS, JODY B (MS, RD, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:B
Last Name:WELLS
Suffix:
Gender:F
Credentials:MS, RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 BONNIE BLUE DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-6198
Mailing Address - Country:US
Mailing Address - Phone:662-380-2147
Mailing Address - Fax:
Practice Address - Street 1:908 BONNIE BLUE DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-6198
Practice Address - Country:US
Practice Address - Phone:662-380-2147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X
MS133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty