Provider Demographics
NPI:1346485554
Name:MALLORY, JASON S (RD, LDN)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:S
Last Name:MALLORY
Suffix:
Gender:M
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 1:924 EVERYMAN CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-5596
Mailing Address - Country:US
Mailing Address - Phone:731-571-0736
Mailing Address - Fax:
Practice Address - Street 1:1224 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4802
Practice Address - Country:US
Practice Address - Phone:931-388-1111
Practice Address - Fax:931-540-4213
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLD0000001968133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered