Provider Demographics
NPI:1629465547
Name:DAMOUR, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DAMOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 W 32ND ST STE 303
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1512
Mailing Address - Country:US
Mailing Address - Phone:417-782-4100
Mailing Address - Fax:417-782-4116
Practice Address - Street 1:1905 W 32ND ST STE 303
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1512
Practice Address - Country:US
Practice Address - Phone:417-782-4100
Practice Address - Fax:417-782-4116
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002021884133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered