Provider Demographics
NPI:1780635870
Name:CALHOUN, BOBBIE JEAN (LD)
Entity Type:Individual
Prefix:
First Name:BOBBIE
Middle Name:JEAN
Last Name:CALHOUN
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 HIGHWAY 322
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-4717
Mailing Address - Country:US
Mailing Address - Phone:662-624-4292
Mailing Address - Fax:662-624-4354
Practice Address - Street 1:800 OHIO AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7200
Practice Address - Country:US
Practice Address - Phone:662-624-2504
Practice Address - Fax:662-627-3629
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0144133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist