Provider Demographics
NPI:1548665391
Name:MADZIN, JENNIFER BUQUO (MS, RD, LDN, CDE, BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BUQUO
Last Name:MADZIN
Suffix:
Gender:F
Credentials:MS, RD, LDN, CDE, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 GLENWOOD DR STE E588
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1176
Mailing Address - Country:US
Mailing Address - Phone:423-206-9025
Mailing Address - Fax:423-206-9026
Practice Address - Street 1:725 GLENWOOD DR STE E588
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1176
Practice Address - Country:US
Practice Address - Phone:423-206-9025
Practice Address - Fax:423-206-9026
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001224133V00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ047596Medicaid