Provider Demographics
NPI:1043832751
Name:WALSH, JENNIFER M (MS, RD, CDE)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:WALSH
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7187 RUSHING WATER CT
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36527-9091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7187 RUSHING WATER CT
Practice Address - Street 2:
Practice Address - City:SPANISH FORT
Practice Address - State:AL
Practice Address - Zip Code:36527-9091
Practice Address - Country:US
Practice Address - Phone:205-370-6896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1474133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered