Provider Demographics
NPI:1144350281
Name:WELLS, JACQUELYN ELAINE (RD)
Entity type:Individual
Prefix:MS
First Name:JACQUELYN
Middle Name:ELAINE
Last Name:WELLS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MAGNOLIA WAY
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-3366
Mailing Address - Country:US
Mailing Address - Phone:601-933-4548
Mailing Address - Fax:
Practice Address - Street 1:570 EAST WOODROW WILSON
Practice Address - Street 2:WIC CENTRAL OFFICE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39215-1700
Practice Address - Country:US
Practice Address - Phone:601-987-4666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0594133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered