Provider Demographics
NPI:1053943225
Name:MONGENE, JILL ANN (MACC RD LDN)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:ANN
Last Name:MONGENE
Suffix:
Gender:F
Credentials:MACC RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4295 KEISLING RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:TN
Mailing Address - Zip Code:38573
Mailing Address - Country:US
Mailing Address - Phone:615-479-0869
Mailing Address - Fax:
Practice Address - Street 1:4295 KEISLING RIDGE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:TN
Practice Address - Zip Code:38573
Practice Address - Country:US
Practice Address - Phone:615-479-0869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005652133V00000X
TN3549133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered