Provider Demographics
NPI:1154910214
Name:LAKE, JESSICA ELAINE (MS, RDN, LD)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ELAINE
Last Name:LAKE
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 CAUGHEY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4098
Mailing Address - Country:US
Mailing Address - Phone:814-580-8808
Mailing Address - Fax:
Practice Address - Street 1:3910 CAUGHEY RD STE 200
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4098
Practice Address - Country:US
Practice Address - Phone:814-580-8808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.09340133V00000X
PADN007374133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty