Basic Information
| Provider Information | |||||||||
| NPI: | 1033889522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BREAULT | ||||||||
| FirstName: | JAMI | ||||||||
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| Credential: | MS, RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4219 E 85TH ST N | ||||||||
| Address2: | |||||||||
| City: | VALLEY CENTER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 67147 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5500 E KELLOGG DR | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672181607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166852221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2021 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 000787 | KS | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.