Provider Demographics
NPI:1447672639
Name:BAILIFF, JENNIFER (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BAILIFF
Suffix:
Gender:F
Credentials:MS, RD, LDN
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-277-1892
Mailing Address - Fax:
Practice Address - Street 1:1900 S HAWTHORNE RD
Practice Address - Street 2:SUITE 170
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3913
Practice Address - Country:US
Practice Address - Phone:336-277-1892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered