Provider Demographics
NPI:1982751517
Name:SIDES, JENNIFER LAURA (RD, LD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAURA
Last Name:SIDES
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 1:7828 PAT BOOKER RD
Mailing Address - Street 2:APT. 712
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-2618
Mailing Address - Country:US
Mailing Address - Phone:806-441-2320
Mailing Address - Fax:
Practice Address - Street 1:12647 OLIVE BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6345
Practice Address - Country:US
Practice Address - Phone:800-325-3982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06855133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered