Provider Demographics
NPI:1811487796
Name:GLENN, JENNY
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:GLENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1362 N GATEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37854-4108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1362 N GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:ROCKWOOD
Practice Address - State:TN
Practice Address - Zip Code:37854-4108
Practice Address - Country:US
Practice Address - Phone:865-354-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN741133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered