Provider Demographics
NPI:1306313200
Name:MAHONEY, JENNIFER NICOLE (RD)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:LIVAUDAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:6222 POTOMAC ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2011
Mailing Address - Country:US
Mailing Address - Phone:314-605-3287
Mailing Address - Fax:
Practice Address - Street 1:10407 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:FRONTENAC
Practice Address - State:MO
Practice Address - Zip Code:63131-2909
Practice Address - Country:US
Practice Address - Phone:314-432-6103
Practice Address - Fax:314-692-0448
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015026976133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered