Healthcare Provider Details

I. General information

NPI: 1306313200
Provider Name (Legal Business Name): JENNIFER NICOLE MAHONEY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER NICOLE LIVAUDAIS RD

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10407 CLAYTON RD
FRONTENAC MO
63131-2909
US

IV. Provider business mailing address

6222 POTOMAC ST
SAINT LOUIS MO
63139-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-6103
  • Fax: 314-692-0448
Mailing address:
  • Phone: 314-605-3287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2015026976
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: