Provider Demographics
NPI:1700045929
Name:BROWN, JENNIFER (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 E 12TH ST
Mailing Address - Street 2:PO BOX 607
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-1525
Mailing Address - Country:US
Mailing Address - Phone:270-527-1496
Mailing Address - Fax:270-527-5321
Practice Address - Street 1:307 E 12TH ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1525
Practice Address - Country:US
Practice Address - Phone:270-527-1496
Practice Address - Fax:270-527-5321
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20079018Medicaid
KY20079026Medicaid