1811938459 NPI number — JODY JEANNE JOHNSON BURT MA, RDN, LN, CNSC

Table of content: JODY JEANNE JOHNSON BURT MA, RDN, LN, CNSC (NPI 1811938459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811938459 NPI number — JODY JEANNE JOHNSON BURT MA, RDN, LN, CNSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURT
Provider First Name:
JODY
Provider Middle Name:
JEANNE JOHNSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, RDN, LN, CNSC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
JODY
Provider Other Middle Name:
JEANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811938459
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2501 W 26TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-2446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-444-9532
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2501 W 26TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57105-2446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-444-9532
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  0544 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0544 . This is a "SD BOARD OF MEDICAL & OSTEOPATHIC EXAMINER LICENSE NUMBER" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 870348 . This is a "COMMISSION ON DIETETIC REGISTRATION NUMBER" identifier . This identifiers is of the category "OTHER".