Provider Demographics
NPI:1699344010
Name:MONTAGUE, JENNIFER NERISON (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NERISON
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 LEEMAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2420
Mailing Address - Country:US
Mailing Address - Phone:406-471-5403
Mailing Address - Fax:
Practice Address - Street 1:41 DONALD B DEAN DR STE A
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3252
Practice Address - Country:US
Practice Address - Phone:207-661-6064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1603133V00000X
86036308133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDI1603OtherLICENSED DIETITIAN
86036308OtherREGISTERED DIETITIAN (CDR)