Provider Demographics
NPI:1477054526
Name:KANE, JENNIFER (RDN, LN, CLC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KANE
Suffix:
Gender:F
Credentials:RDN, LN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 W KENT AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6619
Mailing Address - Country:US
Mailing Address - Phone:406-241-2495
Mailing Address - Fax:406-721-0055
Practice Address - Street 1:825 W KENT AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-241-2495
Practice Address - Fax:406-721-0055
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-23
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-NUTR-LIC-36063133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered