Provider Demographics
NPI:1407375587
Name:COPE, JENNA P (MPH, RD, LD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:P
Last Name:COPE
Suffix:
Gender:F
Credentials:MPH, RD, LD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:P
Other - Last Name:TALLAKSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:HWY 491 NORTH
Mailing Address - Street 2:P.O. BOX 160
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420
Mailing Address - Country:US
Mailing Address - Phone:505-368-6001
Mailing Address - Fax:
Practice Address - Street 1:HWY 491 NORTH
Practice Address - Street 2:P.O. BOX 160
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1148133VN1004X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric