Provider Demographics
NPI:1285331876
Name:DICKISON, JENNFIER L (RND)
Entity type:Individual
Prefix:
First Name:JENNFIER
Middle Name:L
Last Name:DICKISON
Suffix:
Gender:F
Credentials:RND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX T
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-1279
Mailing Address - Country:US
Mailing Address - Phone:208-267-5223
Mailing Address - Fax:
Practice Address - Street 1:1227 MISSION RD.
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805
Practice Address - Country:US
Practice Address - Phone:208-267-5223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1316133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD-1316OtherSTATE OF IDAHO