Provider Demographics
NPI:1619647476
Name:JEFFERY, ANDREA M (RDN, LD)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:M
Last Name:JEFFERY
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 W YOSEMITE ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6786
Mailing Address - Country:US
Mailing Address - Phone:208-821-0055
Mailing Address - Fax:
Practice Address - Street 1:86 W YOSEMITE ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6786
Practice Address - Country:US
Practice Address - Phone:208-821-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1125133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered