Provider Demographics
NPI:1881879567
Name:VISSERS, JENNIFER N (REGISTERED DIETITION)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:N
Last Name:VISSERS
Suffix:
Gender:F
Credentials:REGISTERED DIETITION
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:N
Other - Last Name:EDDINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8702
Mailing Address - Country:US
Mailing Address - Phone:970-624-4439
Mailing Address - Fax:970-490-4156
Practice Address - Street 1:1024 S LEMAY AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3929
Practice Address - Country:US
Practice Address - Phone:970-495-8205
Practice Address - Fax:970-495-7644
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164-004814133V00000X
CO956613133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0407950001Medicare NSC