Provider Demographics
NPI:1801146519
Name:GARDNER, JAIME LOUISE (RD/LD)
Entity type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:LOUISE
Last Name:GARDNER
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 1:3112 W QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9071
Mailing Address - Country:US
Mailing Address - Phone:918-252-7649
Mailing Address - Fax:
Practice Address - Street 1:3112 W QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-9071
Practice Address - Country:US
Practice Address - Phone:918-252-7649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1408133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered