Basic Information
| Provider Information | |||||||||
| NPI: | 1487694576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAUGHERTY | ||||||||
| FirstName: | JAYLENE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1898 FORT RD | ||||||||
| Address2: | BUILDING 71 ROOM 246 | ||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828018320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076723473 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1898 FORT RD | ||||||||
| Address2: | BUILDING 71 ROOM 246 | ||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828018320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076723473 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 810801 | WY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.