Provider Demographics
NPI:1891511606
Name:POLK, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:POLK
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 1:13424 CHERRY TREE CIR
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2824
Mailing Address - Country:US
Mailing Address - Phone:240-527-8814
Mailing Address - Fax:
Practice Address - Street 1:13424 CHERRY TREE CIR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2824
Practice Address - Country:US
Practice Address - Phone:240-527-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX6098133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist