Provider Demographics
NPI:1700962768
Name:HALL, JENNIFER SUSAN (RD, LD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUSAN
Last Name:HALL
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 TRETTEL LN
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1345
Mailing Address - Country:US
Mailing Address - Phone:218-879-1227
Mailing Address - Fax:
Practice Address - Street 1:FOND DU LAC HUMAN SERVICES DIVISION
Practice Address - Street 2:927 TRETTLE LANE
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:218-878-2188
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0515133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN710000120Medicare ID - Type Unspecified
NPP00Medicare UPIN