Provider Demographics
NPI:1477177723
Name:ROGERS, SAMANTHA JO (RD, LDN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:ROGERS
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:MISA
Other - Middle Name:JO
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:117 VANDEN ST APT 303
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-5638
Mailing Address - Country:US
Mailing Address - Phone:615-772-6333
Mailing Address - Fax:
Practice Address - Street 1:117 VANDEN ST APT 303
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-5638
Practice Address - Country:US
Practice Address - Phone:615-772-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000003406133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered