Provider Demographics
NPI:1710344221
Name:BAILEY, JACIE (RD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:JACIE
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5716 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4825
Mailing Address - Country:US
Mailing Address - Phone:801-648-5337
Mailing Address - Fax:801-395-1963
Practice Address - Street 1:5716 MAPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4825
Practice Address - Country:US
Practice Address - Phone:801-648-5337
Practice Address - Fax:801-395-1963
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6046054-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered