Provider Demographics
NPI:1053909119
Name:BACKUS, JENNIFER ALISON (RD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALISON
Last Name:BACKUS
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 1:317 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1615
Mailing Address - Country:US
Mailing Address - Phone:414-430-0434
Mailing Address - Fax:
Practice Address - Street 1:317 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-1615
Practice Address - Country:US
Practice Address - Phone:414-430-0434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86152523133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered