Provider Demographics
NPI:1144422700
Name:JENNISON, KATHERINE M (RD LDN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:JENNISON
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 PONTE VEDRA COLONY CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4710
Mailing Address - Country:US
Mailing Address - Phone:978-807-7205
Mailing Address - Fax:
Practice Address - Street 1:400 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5784
Practice Address - Country:US
Practice Address - Phone:904-819-4404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5590133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered