Provider Demographics
NPI:1396217360
Name:FLACK, JENNIFER ANN (MPH, RDN, LDN, CDE)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:FLACK
Suffix:
Gender:F
Credentials:MPH, RDN, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W MARKET ST
Mailing Address - Street 2:NUTRITION & DIABETES EDUCATION
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611
Mailing Address - Country:US
Mailing Address - Phone:256-233-9146
Mailing Address - Fax:
Practice Address - Street 1:700 W MARKET ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2422
Practice Address - Country:US
Practice Address - Phone:256-233-9146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-01
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2631133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic