Provider Demographics
NPI:1023497781
Name:LEMACKS, JENNIFER L (PHD, RD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:LEMACKS
Suffix:
Gender:F
Credentials:PHD, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-5831
Mailing Address - Country:US
Mailing Address - Phone:850-556-4377
Mailing Address - Fax:
Practice Address - Street 1:105 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-5831
Practice Address - Country:US
Practice Address - Phone:850-556-4377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1640133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered