Healthcare Provider Details

I. General information

NPI: 1548665391
Provider Name (Legal Business Name): JENNIFER BUQUO MADZIN MS, RD, LDN, CDE, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 GLENWOOD DR STE E588
CHATTANOOGA TN
37404-1176
US

IV. Provider business mailing address

725 GLENWOOD DR STE E588
CHATTANOOGA TN
37404-1176
US

V. Phone/Fax

Practice location:
  • Phone: 423-206-9025
  • Fax: 423-206-9026
Mailing address:
  • Phone: 423-206-9025
  • Fax: 423-206-9026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN0000001224
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: