Provider Demographics
NPI:1487328480
Name:GROLL, JEANNINE ANNE (RDN)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:ANNE
Last Name:GROLL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N BEAR RIVER BLFS
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-5184
Mailing Address - Country:US
Mailing Address - Phone:208-406-9586
Mailing Address - Fax:
Practice Address - Street 1:517 W 100 N STE 110
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9826
Practice Address - Country:US
Practice Address - Phone:435-755-6061
Practice Address - Fax:435-994-8362
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363888-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered