Provider Demographics
NPI:1902033087
Name:MOODY, JERRY RAY (MS, RD, CNSD)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:RAY
Last Name:MOODY
Suffix:
Gender:M
Credentials:MS, RD, CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4008 NORDLAND TRL
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109-7937
Mailing Address - Country:US
Mailing Address - Phone:303-814-1511
Mailing Address - Fax:
Practice Address - Street 1:12647 OLIVE BLVD STE 600
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6346
Practice Address - Country:US
Practice Address - Phone:800-325-3982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-593133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered