Provider Demographics
NPI:1386981702
Name:DEFORE, JENNA (RD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:DEFORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:KOEHLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3644 W 46TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-6799
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3644 W 46TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46228-6799
Practice Address - Country:US
Practice Address - Phone:812-239-7936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002145A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered