Provider Demographics
NPI:1134315864
Name:CLOSE, JENNIFER GILLEY (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:GILLEY
Last Name:CLOSE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3013
Mailing Address - Country:US
Mailing Address - Phone:706-594-2449
Mailing Address - Fax:
Practice Address - Street 1:8 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3665
Practice Address - Country:US
Practice Address - Phone:334-756-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-17
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003278133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered