Provider Demographics
NPI:1689076028
Name:POLK, JENNA CROSS (RD, LD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:CROSS
Last Name:POLK
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:REBECCA
Other - Last Name:CROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:PO BOX 90010
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-9010
Mailing Address - Country:US
Mailing Address - Phone:270-745-0942
Mailing Address - Fax:270-745-0683
Practice Address - Street 1:1857 TUCKER WAY
Practice Address - Street 2:STE B
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-6258
Practice Address - Country:US
Practice Address - Phone:270-745-0942
Practice Address - Fax:270-745-0683
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY807619133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK164524Medicare PIN