Provider Demographics
NPI:1841938065
Name:VERMILLION, JENNIFER ELLEN (BASC, LRD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELLEN
Last Name:VERMILLION
Suffix:
Gender:F
Credentials:BASC, LRD
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:702-680-3173
Mailing Address - Fax:
Practice Address - Street 1:332 2ND AVE N
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4528
Practice Address - Country:US
Practice Address - Phone:701-642-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1361133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered