Provider Demographics
NPI:1417209560
Name:KING, JENNA M (RD)
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:M
Last Name:KING
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:M
Other - Last Name:MADORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:120 MAIN ST STE 248
Mailing Address - Street 2:
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072-3527
Mailing Address - Country:US
Mailing Address - Phone:207-450-3773
Mailing Address - Fax:
Practice Address - Street 1:10 HIGH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7653
Practice Address - Country:US
Practice Address - Phone:207-795-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MED11128133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered