Provider Demographics
NPI:1710192588
Name:POLNIAK, JENNIFER OLSEN (RD, CDE, PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:OLSEN
Last Name:POLNIAK
Suffix:
Gender:F
Credentials:RD, CDE, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:303 N KEENE ST STE 301
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8053
Practice Address - Country:US
Practice Address - Phone:573-882-8000
Practice Address - Fax:573-882-6600
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0221025253133V00000X
363A00000X
MO2016024375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
09720278OtherDIABETES EDUCATOR CERTIFI
MO220039284Medicaid
MO2001025253OtherSTATE LICENSE DIETITIAN