Provider Demographics
NPI:1902460298
Name:SALLEY, JACI (CNTP)
Entity Type:Individual
Prefix:
First Name:JACI
Middle Name:
Last Name:SALLEY
Suffix:
Gender:F
Credentials:CNTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E BAYAUD AVE APT E1201
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-2490
Mailing Address - Country:US
Mailing Address - Phone:612-207-5214
Mailing Address - Fax:
Practice Address - Street 1:1091 E BAYAUD AVE APT W1507
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-2759
Practice Address - Country:US
Practice Address - Phone:612-207-5214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist