Provider Demographics
NPI:1629262209
Name:BEAN, JENNIFER CLOOS (RD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:CLOOS
Last Name:BEAN
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 1:8416 WREN CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269
Mailing Address - Country:US
Mailing Address - Phone:704-995-0442
Mailing Address - Fax:
Practice Address - Street 1:11220 ELM LN
Practice Address - Street 2:SUITE 102
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-0715
Practice Address - Country:US
Practice Address - Phone:704-995-0442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001814CR133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered